Non-Communicable Diseases: NPCDCS ... - SIHFW Rajasthan

Non-Communicable 

Diseases: 

NPCDCS & NPHCE 

State Institute of Health & Family Welfare, Jaipur 

SIHFW: an ISO 9001:2008 certified Institution 

1

Structure of Presentation 

NCD 

Why NCDs – Epidemiological Transition 

Risk factors 

Burden of NCDs 

Impact 

Interventions 

• NPCDCS & NPHCE 


2

Risk factors and NCDs 

largely preventable , and Manageable 


3

NCDs: some attributes 

Cause –largely unknown, 

Risk factors 

Non infectious, Latent period, Indefinite onset 

Long Duration, slow progression 

Non reversible changes 

Leading causes of death-63% of all deaths, 

36% in low & middle income countries 

No gender bias 

Preventable by modifying risk factors 


4

Drivers of NCDs 


5

Major NCDs 

Cardiovascular ( HT, CAD, stroke ) 

Renal (Nephritis, Nephrotic syndrome) 

Nervous and mental ( mania, depression) 

Musculoskeletal ( arthritis) 

Respiratory (asthma, emphysema, bronchitis) 

Cancer 

Diabetes 

Obesity 

Blindness 

Degenerative disorders 

Accidents 


6


7

Achievements in Health Sector 

• Crude Death Rate has ↓ 

• Crude birth rate is ↓ 

• Life expectancy has ↑ 

• Smallpox and guinea worm eradicated 

d 

• Leprosy has been eliminated 

• Polio at the verge of eradication( i No 

case since Feb. 2011) 

• IMR ↓ 

• Health care infrastructure – expanded 


8

Epidemiological Transition 

Communicable diseases continue to be a 

public health problem 

• Emerging & Re-emerging infections 

Non-communicable disease are on the rise 

co-existence of communicable diseases and 

increasing i burden of non-communicable 

diseases 


9

Challenges 

↑ Non-communicable diseases 

• Cancers 

• CVDs – CAD, hypertension 

• Obesity 

• Endocrine disorders 

• Chronic bronchitis and Asthma 

• Psychiatric illnesses 

Causes – 

↑ longevity, 

↑ proportion of geriatric population, (2000 to 

2025 pop. >60 shall go from 4.4% to 7.7%) 

lifestyle changes, etc. 


10

Challenges 

Many communicable diseases continue to 

exist as a public health problem 

• Malaria 

• TB 

New emerging and re-emerging infections 

• Plague 

• Dengue fever / DHF / DSS 

• Chikungunya 

• HIV infection / AIDS 


11

Challenges in NCD control & 

Prevention 

Lack of partnerships between een different 

sectors 

Weak surveillance 

Limited access to prevention & Treatment 

Limited it Human resource 

Limited fund allocation 

Limited it commitment t of Industry & Pvt. 

Sector 


12


13

Iceberg 

of 

NCDs 

What the 

physician sees 

What the 

physician 

does not see 


14

Magnitude 

SEAR-2008: 14.5million total deaths 

• 7.9 million (55%) due to NCDs 

(34% occurred before the age of 60 years v/s 

23% in World). 

25% for CVDs, 7-8% cancer, 2.1% Diabetes 

22% of the global NCD deaths occur in the South-East 

Asia Region. 

Hypertension, raised blood glucose and tobacco use 

account for 3.5 million annual deaths in the region 

A 21% increase in NCD deaths is projected in the 

Region over the next 10 years. 

Source: NCD in SEA region: situation & response, 2011 , 

report by WHO 


15

Estimated % of deaths by 

cause, SEA Region, 2008 

Cardiovascular 

chr. Respiratory 

25 

35 cancer 

others 

9.6 

Injuries 

7.8 

2.1 

11 

10 

Source: Global Health Observatory. WHO 2011. 

Diabetes 

communicable, nutritio 

nal, maternal, perinatal 


16

50 

45 

40 

35 

30 

25 

Estimated %of premature deaths (

700 

600 

Age-standardized mortality rates per 

100 000 population by sex, South- 

East Asia 

Region, 2008 

800 736.36 

561.08 

NCD mortality rates are higher 

in males than females 

500 

400 

300 

200 

100 

357.56 

278.79 Male 

Female 

130.47 

113.04 99.2 

64.33 

26.66 26.16 

0 

All NCDs CVDs Cancer Chronic 

Respiratory 

diseases 

Source: Global Health Observatory. World Health Organization 2011. 

Diabetes 


18

Trends in estimated %of deaths 

80% 

70% 

60% 

by cause of death, SEA Region, 

2004 and 2030 

51% 

74% 

NCD deaths are 

projected to increase 

in the coming years 

50% 

40% 

37% 

2004 

2030 

30% 

20% 

14% 

13% 

12% 

10% 

0% 

CD* NCDs Injuries 

*Communicable diseases , maternal and perinatal conditions, nutritional deficiencies 

Source: Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Medicine 

2006, 3(11):e442. 


19

Estimated & Projected Burden of 

Diabetes & CAD, India 


20

Estimated and Projected Deaths 

due to CAD, India 

35 

30 

25 

20 

15 

10 

5 

0 

% of all deaths due to CVDs 

2000 2005 2010 2015 


21

NCD deaths-India(2008) 

Total NCD deaths 

• 2.96 M(Males) 

• 2.273 M( Females) 

% of Deaths under 60 yrs. 

• Males: 38.0 

• Females: 32.1 

Source: World Health Organization - NCD Country Profiles , 2011. 


22

Pop.(2010): 1 224 614 327 

Age standardized Death rates/ 100000 

Total NCD deaths 

Males 

Females 

781.77 571.0 

Cancers 78.8 71.8 

Chr. Resp. dis. 178.4 125.55 

Cardiovascular diseases and diabetes 

386.3 283.0 

Source: World Health Organization - NCD Country Profiles , India ,2011. 


23

Proportional mortality (% of 

total deaths, all ages) 

Cardiovascular 

24 

chr. Respiratory 

37 cancer 

others 

11 

Injuries 

2 

Source: World Health Organization - NCD Country 

Profiles , India, 2011. 

10 

11 

6 


Diabetes 

communicable, nutritio 

nal, maternal, perinatal 

24

Metabolic Risk factor Trends 

126 

Mean Systolic BP 

124 

122 

120 

Male 

Female 

118 

116 

1980 1984 1988 1992 1996 2000 2004 2008 


25

5.8 

Mean Fasting Blood Glucose 

5.6 

54 5.4 

5.2 

Male 

Female 

5 

4.8 

1980 1984 1988 1992 1996 2000 2004 2008 


26

26 

Mean BMI 

24 

22 

Male 

20 Female 

18 

16 

1980 1984 1988 1992 1996 2000 2004 2008 


27

5 

Mean Total Cholesterol 

4.8 

4.6 

44 4.4 

Male 

Female 

4.2 

4 

1980 1984 1988 1992 1996 2000 2004 2008 


28

Reported Cases & Deaths due 

to NCD-Rajasthan 

Source-DM&HS 


29

Diseases wise Reported Cases 

Source-DM&HS 


30

Total Number of Diabetic Cases - 

Rajasthan 

40000 

35000 

30000 

25000 

20000 

15000 

379 992 

26535 

29973 

20565 5 

3820 08 

25 5056 

15164 

34 

104 

Male 

Female 

10000 

5000 

3575 

2727 

0 

2007 2008 2009 2010 2011(Till 

July) 

Source: DM &HS-Rajasthan 


31

District wise Reported Cases of 

Type 1 DM-Rajasthan 

3667 

2693 

4000 

3500 

3000 

Male 

Female 

2500 

1134 

602 

842 

580 

51 

35 

524 

285 

117 

96 

0 

0 

1189 

8388 

1373 

1065 

210 

135 

556 

348 

1744 

1206 

608 

289 

221 

142 

862 

1101 

2000 

1500 

1000 

500 

0 

0 

23 

7 

0 

0 

678 

116 

50 

13 

4 

583 

0 

Source: DM &HS-Rajasthan Jan-Dec 2010 


32 32

Reported Deaths :Type 1 DM- 

District 

Rajasthan 

Male 

Deaths 

Female 

Ganganagar 2 0 

Jhunjhunu 48 34 

Nagaur 0 1 

Jalore 2 0 

Jhalawar 1 0 

Total 53 35 


Source: DM &HS-Rajasthan Jan-Dec 2010 33 33

District wise Reported Cases of 

Type 2 DM 

4500 

Male 

4001 

4000 

Female 

3500 

3000 2642 

2500 

2000 

1500 

1088 

1000 

700 

400 315 

500 

72 41 

0 

Ganganagar Hanumangarh Bikaner Jhunjhunu 



34

District 

Reported Deaths of 

Type 2 DM 

Male 

Deaths 

Female 


Junjunu 9 1 

Karauli 0 1 

Jaipur 38 24 

Pali 2 1 

Total 52 30 



35 35

Reported Cases of Cancer-Rajasthan 

4500 

4000 

3500 

3340 

4497 

Male 

Female 

3000 

2865 

2500 

2000 

2275 

1710 

1516 

1500 

1000 

500 

0 

246 184 180 183 

2007 2008 2009 2010 2011 (Till July) 

Source -DM&HS SIHFW: an ISO 9001:2008 certified Institution 

36

Reported Cases of Deaths Due 

to Cancer-Rajasthan 

60 

53 

Male 

Female 

50 

40 

40 

26 

30 

20 

26 

20 

15 

10 5 

4 

1 

1 

0 

2007 2008 2009 2010 2011 (Till July) 

Source -DM&HS SIHFW: an ISO 9001:2008 certified Institution 

37

10000 

District –wise reported cancer 

cases-Rajasthan 

Male 

Female 

4179 2522 

1000 

100 

10 

1 

14 

43 

15 34 12 

3 

4 

3 

2 

2 

01 0 10 0 

1 

0 

28 

22 

16 

8 

5 6 

2 

1 1 

55 

24 

12 

356 

361 

Source -DM&HS (Jan to July.2011) SIHFW: An ISO:9001:2008 certified Institution 

38

District –wise reported Cancer 

Deaths 

District Male Female 


Jaipur 46 23 

Jalore 2 0 

Pali 2 2 

Jhalawar 2 0 

Total 53 26 

Source -DM&HS (Jan to July.2011) SIHFW: An ISO:9001:2008 certified Institution 39

Expenditure on Cancer 

Prevention 

2007-08 2008-09 2009-10 2010-11 

(Rs in (Rs in (Rs in (Rs in 

crores ) crores ) crores ) crores ) 

Cancer 60.30 142.46 69.65 85.00 

Control 

NCCP 46.30 33.60 28.25 55.00 

Tobacco 

control 

13.98 33.86 16.40 30.00 

Source-NHP 2010 

SIHFW: An ISO:9001:2008 certified Institution 

40

SIHFW: An ISO:9001:2008 certified Institution 41

Why NCDs considered a 

burden 

Disease occurrence (Incidence+ 

Prevalence) is increasingi 

Lifestyles are changing ↑ risk 

↑ life expectancy ↑ in absolute 

numbers of elderly persons 

↓ Crude Birth Rate compounded with ↑ life 

expectancy ↑ in proportion of geriatric 

population (or geriatric dependents) 

Thus, occurrence of cases of NCDs is 

expected to increase further with time 


Implications of ↑ burden of 

NCDs 

↑ Budgetary allocation to prevention and 

control of NCDs 

Impoverishment of already poor on account 

of continued treatment over long periods 

↑ investment in human resources for health 

sector more oedoctos, doctors, more oenurses, uses, more oe 

LTs, more dieticians, etc. 

↑ investment of drugs further ↑ in nonaffordability 

of many for treatment 

Effect on society – nuclear families, etc. 


NCD Impacts on MDG 

MDG-2 

(universal primary 

education) 

•Costs for NCD health care, medicines, tobacco 

and alcohol l consumption eat on householdh resources that might be available for education. 

•Problem acute in poor families 

MDGs 4 and 5 

(Maternal and Child 

health) 

•Rising prevalence of high BP & gestational 

diabetes increasing the adverse outcomes of 

pregnancy & 

maternal health 

•Mothers who smoke & breastfeed for shorter 

period & have lower quantities of milk that is less 

nutritious 

•Exposure to second-hand tobacco smoke 

increases the risks of childhood RI , Sudden 

infant death and Asthma 


MDG-6 

NCD burden threatenst the 

(Combat HIV/AIDS, malaria possibility to effectively control 

and other diseases) 

tuberculosis 

MDG-8 

(Provide access to affordable 

essential drugs in developing 

countries) 

access to essential drugs are 

limited largely to AIDS, TB & 

Malaria 


Economic Impact 

loss of productivity it -absenteeism and inability 

to work 

Each 10% rise in NCDs is associated with 

0.5% lower rate of annual economic growth 

macroeconomic analysis 

From 2005 to 2015, India lost $ 237 billion 

(1.5% of the GDP). 


2% annual reduction in Chronic Disease Death 

Rates in India will result in economic gain of 15 

billion dollars over the next 10 years WHO 

Per-capita income in India would increase by 

87%. 

Source-Report of the Working Group on Disease Burden for 12th Five Year Plan 


Deaths (Total 10.3 million) 

11% 

29% 

DALYS (total 291 million) 

14% 

11% 

4% 

3% 

1% 

36% 

7% 

42% 

25% 

8% 7% 

2% 

Cardiovascular diseases 

Cancer 

Chronic respiratory diseases 

Diabetes 

Other chronic diseases 

Communicable diseases, perinatal & maternal conditions, & nutritional deficiencies 

Injuries 


Answer to the problem: 

ACT NOW 

Preventive Strategies for NCDs 


Immunity & 

Death 

Resistance Chronic 

state 

Disability 

Presymptom 

Recovery 

Susceptibi atic stage Clinical disease Convalescen 

lity 

ce 

Pre- 

Tissue Pathogenesis- Early 

A, H, E 

changes interaction 

Pathogenesis- 

Tissue changes 

Pathogenesis 

Levels of Primary Secondary Tertiary 

Prevention 

Prevention. 

Modes 

Health. 

Promotion 

Specific 

Protection 

Early Disability Limitation/ 

diagnosis Rehabilitation 

Treatment 


50

Risk factor/disease 

Tobacco use: 

Use of alcohol: 

Unhealthy diet: 

Cost effective interventions 

Interventions 

Protect people from tobacco smoke 

Warn about the dangers of tobacco 

Enforce bans on tobacco advertising 

Raise taxes on tobacco 

Enforce bans on alcohol advertising 

Restrict access to retailed alcohol 

Raise taxes on alcohol 

Reduce salt intake in food 

Replace trans fat with polyunsaturated t fat 

Cardiac diseases and diabetes: 

Provide counseling and multi-drug therapy 

(including glycaemic control for diabetes 

mellitus) for people with 10-year 

cardiovascular risk >30% 

Treat acute myocardial infarction (with aspirin) 

Cancers 

Hepatitis B vaccination to prevent liver cancer 

Detection and treatment of precancerous 51 

lesions

General Objectives 

es 

To strengthen prevention and control of 

chronic non-communicable diseases by 

tackling the major risk factors 

To reduce premature mortality and 

morbidity, and 

To improve quality of life 


Action at National Level: 

Two components 

• Cancer 

NPCDCS 

• Diabetes, Cardiovascular Diseases & 

Stroke 


NPCDCS :Objectives 

Prevent and control common NCDs 

through behavior and life style changes, 

Provide early diagnosis and 

management of common NCDs, 

Build capacity at various levels of health 

care for prevention, diagnosis and 

treatment of common NCDs, 

Train human resource within the public 

health setup and 

Establish and develop capacity for 

palliative & rehabilitative care. 


Strategies 

Prevention through behavior change 

Early Diagnosis 

Treatment 

Capacity building of human resource 

Surveillance, Monitoring & Evaluation 


States to Implement NPCDCS 


Services 

Preventive, promotive , curative and 

supportive services (core and integrated 

services) 

Health promotion, psycho-social counseling, 

management (out-and-in-patient), day care 

services, home based care, palliative care 

and referral 

Linkages of District Hospitals to private 

laboratories and NGOs for continuum of 

care and support for outreach services. 


Facility 

level 

PHC 

CHC 

Services 

Services: 

Health promotion for behavior change; 

‘Opportunistic’ Screening using B.P measurement 

and blood glucose by strip method ; Referral of 

suspected cases to CHC 

Prevention and health promotion including 

counseling ; Early diagnosis through clinical and 

laboratory investigations (Common lab 

investigations: Blood Sugar, lipid profile, ECG, 

Ultrasound, X ray etc.); Management of common 

CVD, diabetes and stroke cases (out patient and in 

patients.); Home based care for bed ridden chronic 

cases ; Referral of difficult cases, HMIS 


Facility 

DH 

Services 

Early diagnosis of diabetes, CVDs, Stroke and 

Cancer ; Investigations: Blood Sugar, lipid 

profile, Kidney Function Test (KFT),Liver 

Function Test ( LFT), ECG, Ultrasound, X ray, 

colposcopy py , mammography etc. (if not 

available, will be outsourced); Medical 

management of cases (out patient , inpatient 

and intensive Care ) ; Follow up and care of bed 

ridden cases; Day care facility; Referral; Health 

promotion for behavior change ; Trainings, 

HMIS 


Institutional 

Framework 

Services available under 

NPCDCS at different levels 

Public Health 

Services 

Infrastructure 

t 

National NCD 

State NCD 

Tert . 

Level 

Tertiary cancer care centers 

in Medical Colleges/RCC 

District NCD Cell 

Block CHC 

(Rogi Kalyan 

Samiti) 

District hospital 

NCD Clinic 

Cardiac Care Unit 

Cancer Care Facility 

CHC 

NCD Clinic 

(Early diagnosis & mgt. Laboratory 

Investigations, Home based care, Referral 

Health Promotion; Early 

diagnosis & management; 

Home Based Care; Day 

Care Facility 

Ref. 

Village Health 

Committee 

Sub Centre 

Screening facility 

(Health Promotion; Opportunistic Screening; Referral) 


Institutional Framework 

Integration with NRHM 

TRGs( One for Cancer, other for CAD, S, & D) 

State Health Society 

• NPCD cells 

• Retain funds for state level activity and 

release GIA to the District Health Societies. 

District Health Societies 

• NPCD cells 

• Utilization of funds and quarterly the 

financial management report 


Composition 

State Program Officer 

2. Program Assistant 

3. Finance cum Logistics 

Officer 

4. Data Entry Operators 

(2) 

State NCD cell 

ToR 

State action plan 

Develop district i t wise NCD 

mapping, 

Trainings 

Manpower 

Fund flow and SOE/ UCs 

epidemiological profiling 

Convergence with NRHM 

Availability of palliative and 

rehabilitative services 

Monitoring 

Public awareness 



Surveillance 

Screening 

Services 

Statistics 


Screening 

MO to do: 

To conduct comprehensive examination to 

diagnose, investigate and manage the 

cases appropriately. 

To rule out complications or advanced 

d 

stage. 

To refer complicated cases to higher h care 

facility 

To provide follow up care to the patients 

Health promotion 

Data and record 


Health promotion activities i i – (i)Educate 

regarding common risk factors, increased 

intake of healthy foods (ii) increased physical 

activity through sports, exercise, etc. (iii) 

avoidance oda of tobacco and alcohol aco o and (iv) 

stress management. 

Risk assessment and management through 

opportunistic screening 

Motivate and create role models in the 

community 


Work closely with other sectors/ departments for 

NCD prevention 

Management of patients suffering from Cancer, 

Diabetes, CVDs and Stroke referred from 

different centers 

Establish an effective referral mechanism with 

the nearest medical colleges 

Supervision of the activities undertaken by 

paramedical workers 

Assist resource centers/ institution in organizing 

the training for different cadre of health workers 


Nursing staff: 

• To assist in examination and 

investigation 

• To teach the patient and family about risk 

factors of NCDs and promote patients 

wellbeing 

• To assist in follow up and care 

Counselor: 

• To provide counseling on diet and life 

style management 

• To assist in follow up care and referral 


Surveillance 

Surveillance is the ongoing 

collection, analysis, and use of 

health data for the 

planning, implementation, and 

assessment of disease control 

"information for action” 


Surveillance helps 

• Identify extent of the problem 

• Map emerging patterns and trends 

• Measure progress in primary prevention 

• Contribute to policy making 


Risk Factor Surveillance: Focus 

… selected risk factors associated 

with major NCDs and amenable to 

interventions. 

… simple surveillance systems. 

… standard definition and methods. 

… surveillance for primary 

prevention of NCDs. 


Selecting risk factors 

• Greatest impact on NCD mortality and 

morbidity; 

• Modifiable by intervention; 

• Validated measurement; 

• Meaningful comparisons possible; 

• Measurement can be obtained following 

ethical standards. 


Risk factors common to major 

non-communicable conditions 

Risk Factor 

Condition 

CAD Diabetes Cancer Respiratory 

Smoking 

Alcohol 

Nutrition 

Physical Inactivity 

Obesity 

BP 

Blood glucose 

Blood Lipids 


The WHO STEP approach to 

Surveillance of NCD Risk Factors 

Step 1 

Step 2 

Step 3 

xity 

Complex 

At each step 

Core 

Expanded 

Optional 


Levels of Risk Factor Surveillance 

Measures 

Level 

Core 

Expanded 

Optional 

Step 1 

Step 2 

Step 3 

(Verbal) (Physical) (Biochemical) 

Demographics, 

Tobacco, Alcohol, 

Nutrition, 

Physical activity 

Education, 

Occupation 

Indicators, 

Knowledge+ 

attitudes regarding 

health Health-related 

Quality of life and 

health-related 

behaviour 

Measured 

weight + height, 

Waist girth, 

Blood pressure 

Hip girth, 

Skinfolds, 

Pedometer 

Cholesterol, 

Fasting blood 

sugar 

HDL-Chol, 

Ti Triglycerides 

id 

Urine, etc. 


Actions at Hospitals 

Counseling of identified patients of NCDs: 

• What is the illness 

• What is the prognosis 

• What complications can arise 

• What drugs to take – proper dosage, importance 

of regularity of drug intake, possible side effects 

• What other interventions can reduce the severity 

of illness 

Habitual physical exercise 

Balanced diet 

Meditation 



Proper depiction / display of health 

education messages / posters 

Educate women on self-examination of 

breast 

Educate persons coming to the hospital 

on risk factors for different NCDs (health 

education corners, documentaries may be 

shown on TV screens, etc.) 



Screening for early diagnosis of NCDs 

• Routine measurement of BP of all 

patients 

• Screening tests In high-risk cases 

• Pap smear examination 

• Routine examination of oral cavity for 

early signs of cancer 

Training of different categories of health 

staff 



Risk Factors in NCDs 



Structure re of presentation 

Risk factor 

Types of Risk Factors 

Risk Factor Assessment and 

management 

Primary Prevention through Health 

Promotion 

Role oeof Medical edca Officer of DH,CHC,PHC 

C, C 

under NPCDCS and NPHCE 


Risk factors and NCDs 

largely preventable , and Manageable 


Risk factor in NCD 

Any attribute, characteristic or exposure of an 

individual that increases the likelihood of 

developing a disease or injury. 

A determinant that can be modified by 

intervention 

Cumulative effect- Dose and Time response 

Co-existence 


only suggestive 

Risk factors 

Presence does not imply that t the disease will 

occur neither absence is guarantee of 

disease 

Observable /identifiable prior to event 

Smoking, obesity 

Combination is purely additive or synergistic 

Smoking and occupational exposure 

:bladder cancer 

Smoking ,high blood cholesterol and HT 


Risk factors 

May be truly causative 

smoking and lung cancer 

May be merely contributory t to undesired 

d 

outcome 

lack of physical exercise and CAD 

Predictive only in statistical sense 

illiteracy for IMR 


Risk factors 

Modifiable 

• Behavioral 

Tobacco 

Alcohol 

Physical inactivity 

Nutrition 

• Physiological 

BMI 


Blood glucose 

Cholesterol 

Non-Modifiable 

• Age 

• Heredity, Genetic 

• Gender 

• Ethnicity 


NHD of NCD 

Changes in life style 

stress 

Excess intake 

Smoking 

Lack of Physical activity 

Emotional disturbance 

Obesity 

Hypertension 

Aging 

Hyperlipidemia 

Atherosclerosis 

Thrombotic tendency 

Coronary Occlusion 

Myocardial 

infarction 

Arterial 

changes 


Risk factors common to major 

non-communicable conditions 

Risk Factor 

Condition 

CAD Diabetes Cancer Respiratory 

Smoking 

Alcohol 

Nutrition 

Physical Inactivity 

Obesity 

BP 

Blood glucose 

Blood Lipids 


The WHO STEP approach to 

Surveillance of NCD Risk Factors 

Step 1 

Step 2 

Step 3 

xity 

Complex 

At each step 

Core 

Expanded 

Optional 


Levels of Risk Factor Surveillance 

Measures 

Level 

Step 1 

(Verbal) 

Step 2 

(Physical) 

Step 3 

(Biochemical) 

Core 

Demographics, 

Tobacco, Alcohol, 

Nutrition, 

Measured weight 

+ height, 

Waist girth, 

Cholesterol, 

Fasting blood 

sugar 



Expanded 

Optional 

Education, 

Occupation 

Indicators, 

Knowledge+ attitudes 

regarding health 

Health-related Quality 

of life and healthrelated 

behaviour 

Hip girth, 

Skinfolds, 

Pedometer 

HDL-Chol, 

Triglycerides 

Urine, etc. 


STEPS emphasizes that small amounts 

of good quality data are more valuable 

than large amounts of poor data. It is 

based on the following two key 

premises: 

• Collection of standardized data, and 

• Flexibility for use in a variety of country 

situations and settings. 

SIHFW: an ISO 9001: 2008 certified institution 

91

Population Focus 

STEPS uses a representative sample of 

the study population. 


92


93

STEPS Instrument 

STEPS Instrument covers three different 

levels "steps" for risk factor assessment. 

These steps are: 

• Questionnaire - self reported behaviors 

and life style risk factors 

• Physical measurements -blood pressure 

and anthropometric status 

• Biochemical measurements - collection 

of blood samples 


94

Step1:Questionnaire Based 

Assessment 

Description: Gathering demographic and 

behavioural information by questionnaire in a 

household setting. 

 

Purpose: To obtain core data on: 

• Socio-demographic information 

• Tobacco and alcohol aco o use 

• Nutritional status 

• Physical activity 

Recommendation: All countries/sites should 

undertake the core items of Step 1. 


95

Step 2: Simple Physical 

Measurements 

Description: Collecting physical 

measurements with simple tests in a 

household setting. 

Purpose: To build on the core data in 

Step 1 

and determine the proportion of adults that: 

• are overweight and obese, and 

• have raised blood pressure 

Recommendation: Most countries/sites 

should undertake Step 2. 


96

Step 3: Biochemical 

Measurements 

Description: Taking blood samples for 

biochemical measurement in a clinic. 

Purpose: 

To measure prevalence of 

diabetes 

or raised blood glucose and abnormal 

blood lipids. 

Recommendation: Only recommended 

for well resourced settings 

Note: Within each Step, there are three levels of data 

collection, core, expanded and optional levels 


97

Core Items Expanded Items 

Optional 

Modules 

Step 1: Basic Expanded demographic Mental health, 

Behavi demographic information including intentional and 

oural information, years at school, unintentional 

including ethnicity, marital status, injury and 

age, sex, employment status, violence and oral 

literacy, and household income health. 

highest level of Smokeless tobacco use 

Education 

Tobacco use 

Past 7 days drinking 

Oil and fat consumption 

Objective 

measure of 

Alcohol History of blood physical 

activity 

consumption pressure, treatment for behavior 

Fruit and raised blood Pressure 

vegetable 

History of diabetes, 

Consumption 


treatment for diabetes 


98

Core Items 

Expanded 

Items 

Optional 

Modules 

Step 2: 

Physical 

measurements 

Weight and 

height 

Waist 

circumference 


Hip 

circumference, 

Heart rate 

Skin fold 

thickness, 

assessment of 

physical 

fitness 


99

Core Expanded Optional 

Items Items Modules 

Step 3: Fasting Fasting HDL- Oral glucose 

Biochemical 

measurements 

blood 

sugar 

Total 

cholesterol 

cholesterol 

and 

triglycerides 

tolerance test, 

urine 

examination, 


100

Behavioral Risk Factors 

“Actions/Behavior ior that people engage in 

that put their health at risk” 

NCDs 

Diseases of affluence 

Diseases due to urbanization 

Diseases of developed world 

Chronic diseases 

Bio-behavioral 

disorders 


101

Behavioral Risk Factors 

2008 estimated prevalence (%) 

males females total 

Current daily tobacco 25.1 20 2.0 13.9 

Smoking 

Physical inactivity 10.8 17.3 14.0 



102

Modifiable Risk Factor: 2008 estimated prevalence 

(%) 

Males Females 

Total 

Raised BP 33.2 31.7 32.5 

Raised blood glucose 10.00 10.00 10.00 

Overweight 9.9 12.2 11.0 

Obesity 13 1.3 24 2.4 19 1.9 

Raised cholesterol 25.8 28.3 27.1 



103

A. Cardio vascular diseases 

‣ Atherosclerosis 

‣ Increased level of C reactive protein 

(CRP). 

‣ Low physical inactivity 

‣ Smoking 

‣ Unhealthy diet 


B. Diabetes 

‣ Obesity 

‣ Sedentary Life style 

‣ Unhealthy eating habits 

‣ Lack of regular exercise 

‣ Genetics & family history 

‣ High blood pressure & high 

cholesterol 

‣ Increased age 


C. Stroke 

1. Controllable Risk Factors: 

‣ High Blood Pressure 

‣ Atrial Fibrillation 

‣ High Cholesterol 

‣ Diabetes 

‣ Atherosclerosis 

‣ Circulation Problems 

‣ Tobacco Use and Smoking 

‣ Alcohol Use 

‣ Physical Inactivity 

‣ Obesity. 


D. Cancer 

‣ Environment 

‣ Life style 

‣ Tobacco addicted 

‣ Over weight 

‣ Low fruit or vegetable intake 

‣ Low physical inactivity 

‣ Alcohol addiction 

‣ Air pollution 

‣ Sexually transmitted infections 


Factors 

Risk Factors 

% of cancer deaths (35–64 yrs) 

Best estimate 

Tobacco 30-40 

Alcohol o 3-10 

Rep. & Sexual behavior 10 

Occupation 6–8 

Pollution 2 

Industrial Products 1 

Medicines &Medical 

1 

procedures 

Geophysical factors 3 


108

Risk factors and level of NCD 

prevention ention and management 

Behavioral RF Physiological RF Disease Outcome 

Unhealthy Diet BMI (Obesity) Diabetes 

Physical inactivity Hypertension Heart disease 

Hyper-cholesterolemia 

l Stroke 

Tobacco 

Alcohol 

Stress 

High Blood sugar level 

Cancer 

Chronic respiratory 

disease 

LEVELS OF PREVENTION 

Primary Prevention Secondary Prevention Tertiary Prevention 

Health promotion Case management & HP Case management 


Risk Assessment And 

Management 

There should be evidence-based approach on how 

to reduce the occurrence of first clinical events of 

coronary heart disease (CHD), cerebrovascular 

disease (CeVD) and peripheral vascular disease 

(PVD) in the population. 

The evidence-based guidelines provide guidance 

on which specific preventive actions to initiate, and 

with what degree of intensity. The accompanying 

World Health Organization/ International Society of 

Hypertension (WHO/ISH) risk prediction charts 

enable the estimation of total cardiovascular risk of 

people in the first category. 


110

Goals of implementing these 

guidelines 

The goals are to prevent CHD, CeVD and PVD events 

and Cancer by lowering risk. The recommendations 

assist people to: 

• Quit tobacco use, or reduce the amount smoked, or 

not just start the habit 

• Make healthy food choices 

• Be physically active 

• Reduce body mass index, waist hip ratio/waist 

circumference 

• Lower blood pressure 

• Lower blood cholesterol and low density lipoprotein 

cholesterol (LDL-cholesterol) 

• Control hyperglycemia 

• Take anti platelet therapy when necessary. 


111

Referral to a specialist facility 

Referral is required if there are clinical features 

suggestive of: 

• Acute cardiovascular events such as: heart 

attack, angina, heart failure, arrhythmias, stroke, 

and transient ischemic attack. 

• Secondary hypertension, malignant 

hypertension. 

• Diabetes mellitus (newly diagnosed or 

uncontrolled). 

• Established cardiovascular disease (newly 

diagnosed or if not assessed in a specialist 

facility). 

• Suspected lesions for Cancer 

• People needing medical therapy to quit smoking. 


112

Follow up 

Once the condition of the above 

categories of people (except with 

suspected lesion) is assessed and 

stabilized, they can be followed up in a 

primary care facility based on the 

recommendations provided in Manual of 

MO. 

They will need periodic reassessment in 

specialty 


113

Grading cardiovascular risk 

using charts for making 

treatment decisions 

Some individuals id are at high 

cardiovascular risk because they have 

established cardiovascular disease or 

very high levels of individual risk factors. 

Risk stratification is not necessary for 

making treatment decisions for these 

individuals as they belong to the high 

risk category; all of them need intensive 

lifestyle interventions and appropriate 

drug therapy . 


114

High risk 

With established cardiovascular disease 

Without established CVD who have a 

total cholesterol ≥ 320 mg/dl or low 

density lipoprotein (LDL) cholesterol ≥ 

240 mg/dl or TC/HDL-C (total 

cholesterol/high density lipoprotein 

cholesterol) ratio >8 

Without established CVD who have 

persistent raised blood pressure of ≥160/ 

≥100 mmHg 

With renal failure or renal impairment. 


115

WHO risk prediction chart 


116

If cholestrol can not be measured 


117

Use of chart 

Step 1 Select the appropriate chart depending on 

the presence or absence of diabetes 

Step 2 Select male or female tables 

Step 3 Select smoker or non smoker boxes 

Step 4 Select age group box (if age is 50-59 years 

select 50,if 60-6969 years select 60 etc) 

Step 5 Within this box find the nearest cell where the 

individual’s systolic blood pressure (mm Hg) 

and total blood cholesterol level (mg/dl) 

cross. The color of this cell determines the 10 

year cardiovascular risk. 


118

Prevention of CVD (according to 

individual total risk) 

10 year risk Risk 

classification 

cat Intervention 

Risk

CVD risk may be higher if 

following are already present 

Already on antihypertensive therapy 

Premature menopause 

Approaching the next age category or systolic blood 

pressure category 

Obesity (including central obesity) 

Sedentary lifestyle 

Family history of premature CHD or stroke in first degree 

relative (male


Components 

Prevention through behaviour change 


Medical treatment 

Capacity building of human resource. 

Supervision, monitoring and evaluation 


121

Key Area 

Health 

Promotion 

Key Interventions for NPCDCS 

Activities 

• Public awareness through multi-media 

• Counseling for healthy lifestyle (Balanced diet, 

regular exercise, avoid alcohol and tobacco) 

Early 

• Screening of persons above 30 years and all 

Diagnosis 

pregnant women for diabetes and hypertension at all 

levels; facilities up to Sub-centre level 

Case 

Management 

Capacity 

Building 

Management & 

Monitoring 

• Facilities for diagnosis and treatment (NCD Clinic) at 

CHC level & above 

• CCU at District Hospital and above 

• Treatment of cancer at District Hospital & above 

• Infrastructure Development &Equipment 

• Training of human resources at all levels 

• NCD Cell at National, State & District level 

• Surveillance, monitoring & evaluation 

• Regular review meetings 


122

Thank you 


123

Diet, Life Style Modification 

& NCDs 


124

Problem on the rise : NCDs 

MI 

HT 

COPD 

CVD 

Diabetes 

Stroke 

Cancer 

Overweight 

Smoking 

Alcohol 

Unhealthy diet 

Env. Pollution 

Physical inactivity 

Hit the trunk, branches will fall automatically 

SIHFW: an ISO 9001: 2008 certified Institution 125

Modifiable risk factors for NCDs 

↑BMI 

Obesity 

↑ Blood 

cholesterol 

Unhealthy 

Diet 

↑ Blood 

glucose 

↑Blood 

pressure 

Tobacco 

Alcohol 

NCDs 

Physical 

inactivity 


Major diet related NCDs 

Diabetes 

Cancer 

CVD 

Obesity 

High blood 

pressure 

Stroke 


Diet and NCDs 

Dietary factors Mechanisms Health risks 

Excess energy 

intake ↑ 

Total Fat ↑ 

Adipose tissue NIDDM, CHD, Hormone 

development ↑ , dependent ( breast )or GI 

metabolic changes 

cancer , osteoarthritis , 

gallbladder diseases 

Passive 

NIDDM, CHD, P:ratate cancer 

overconsumption 

o , breast cancer ce , colorectal o cancer 

Animal fat ↑ Unclear fat metabolism 

by products 

Saturated fat ↑ TC ↑, LDL ↑, TG ↑, 

HDL ↓ 

Colon cancer 

Arthrosclerosis, CHD, 

Hypertension, NIDDM 


Type of 

cancers 

Risk factors 

Diet Related-Cancers 

Prevention 

Cancers oforal oral 

Alcohol 

Management of 

cavity , pharynx Tobacco 

obesity 

and esophagus Obesity / Overweight 

↑ intake of fruits 

Stomach cancer 

Colorectal 

cancer 

Micronutrient deficiencies related to 

↓ Intake of fruits , vegetables and animal 

products 

Consumption of foods at very high ( thermal) 

and vegetables ad 

animal products 

temperatures 

Infection with helicobacter pylori 

↑ intakes of fruits 

Increased intakes of traditionally preserved and vegetables ( 

salted foods ,( meats and pickles) 

vitamin C) 

Obesity / Overweight 

↓ Physical activity 

↑ intake of meats and fats 

↑ intake of preserved and red meat 

SIHFW: an ISO 9001: 2008 certified Institution 

↑ intake of fruits , 

vegetables, 

dietary fibers and 

calcium 

↑Folate 

129 

consumption

Type of cancers Risk factors Prevention 

Liver cancer 

Pancreatic cancer 

Chronic infection with Hepatitis B 

Aflatoxins contaminated foods 

Excessive alcohol consumption 

Obesity / Overweight 

↑ intake of red meats 

↓ alcohol 

consumption 

↑ Intake vegetables 

and fruits 

Lung cancer ↑Smoking (↑ risk 30 times ) 

↑ Intake of fruits 

↓ intake of fruits , veg. and related and veg. 

nutrients ( β- carotene ) 

Breast cancer 

Endometrial cancer 

Age at Menarche 

Obesity , Alcohol 

Obesity ( 3 times ↑ risk in obese 

women ) 

↑ Saturated and total fats 

Prostate cancer ↑Intakes of red meat , 

↑dairy products 

↓ total fats / 

saturate fats 

Vit. E, selenium , 

lycopene has 

protective effects 

130 

Kidney cancer Overweight / obesity Weight 

SIHFW: an ISO 9001: 2008 certified Institution management

Prominent risk factor 

Disease 

Heart disease 

Some types of 

Cancers 

Stroke 

Modifiable- Risk factors 

Smoking, HTN, Dyslipidemia, 

Diabetes, Obesity, Sedentary habits, 

Stress 

Smoking, alcohol, solar radiation, 

ionizing radiation, work-site hazards, 

environmental pollution, medications, 

infectious agents, dietary factors, 

Obesity 

High BP, Elevated cholesterol, 

smoking, obesity / overweight 

Obesity 

Diabetes 

Obesity, diet 


Dietary risk factors 

Total fats 

Saturated fats 

Sugars 

Salt 

Alcohol 

Refined grains 

Foods of animal origin 


Life Style Modification 

Primary Prevention ention through health 

promotion 

Diet 

Physical Activity 

Weight Control 

Tobacco Cessation 

Alcohol l (moderation) 


133

Obesity: The other side of 

Killer lifestyle disease 

poor nutrition 

Pandora box of health issues + emotional 

troubles 

Public health challenge 

Overweight is defined as a body mass index 

(BMI) of 25 to 29.9 kg/m 2 . 

Obesity is defined as an excess of total body 

fat more than a BMI of ≥30 kg/m 2 . 


Burden of the Bulge 

In India 1 in 6 women and 1 in 5 men are 

overweight (WHO) 

1.2 billion people p worldwide are officially classified 

as overweight. (WHO) 

> 25 % of Indians are overweight & > 3% are Obese 

(3 crore Indians). 

Death rates increases by 200 % for men and women 

who are significantly overweight 

WHO predicts that by 2015, about 2.3 billion adults will be overweight and over 700 

million people will be classified as obese. 

Source: Obesity foundation of India 


Types of obesity 

Gynecoid & Android 

Gynecoid : Lower-body 

obesity--Pear shape 

‣ Encouraged by estrogen 

and progesterone 

‣ Less health risk than 

upper-body obesity 


Android : Upper-body obesity--apple 

shape 

‣ Associated with more heart disease, HTN, 

Type II Diabetes 

‣ Encouraged by testosterone and excessive 

alcohol l intake 

‣ Defined as waist measurement of > 40” for 

men and >35” for women (WHO) 

Asian women more than 31 inches. 

Asian men more than 35 inches. 

Risk factor 

for NCDs 


Central obesity 

The waist circumference and waist to hip ratio are 

useful for estimation of central obesity 

Central obesity ∝ Chronic Degenerative Diseases 

Central obesity is a risk factor for diabetes and Indians are 

genetically susceptible to weight accumulation around waist 


Assessment of central obesity 

Waist to Hip Ratio of more than 0.9 in 

men and more than 0.8 in women is 

associated with increased risk of several 

chronic diseases. 

The waist circumference cut off levels for 

Ai Asian Idi Indians are 80C Cm for women and 

90 cm for men 


Measuring waist circumference 

Locate the top of the hip bone 

Place the tape measure evenly around the bare 

abdomen at the level of this bone 

Read the tape measure and record the same 

Ensure the tape is sung but does not push tightly 

into the skin. 

Measure waist circumference after breathing out 

normally; do not “suck in” the stomach. 


Why is this happening 

Drivers of the obesity epidemic 

Societal changes + Worldwide nutrition 

transition. 

Economic growth 

Modernization 

Urbanization 

Globalization of food markets 


Transitional Facets 

Development + Urbanization 

Nutritional 

transition 

Epidemiological 

transition 


Nutrition transitions: Absolute cause 

Changes in food handling processes 

Marketing 

Media Exposure 

Women in labor market 

Life style changes with easy money 

• Sedentary nature of work, low physical activity 

• Ready to eat junk food 

Affluence, Availability, Accessibility 


Heredity 

Unhealthy eating habits 

Low physical activity level 

Causes of Obesity 

Metabolic errors in energy utilization 

Insulin Imbalance :favoring fat deposition. 

Low /high birth weight ( < 2500 ; > 3500 ) 

Obesogens : 

• School environment, family customs and practices, 

• Food advertising and labeling policies, 

• Obesity during pregnancy and after menopause. 


Body Mass Index (BMI ) 

Quetlet’s Index 

Tool to calculate adiposity 

Developed by Adolphe Quetelet 

Risk indicator: increased BMI, increased risk 


BMI Calculationlation 

BMI = Weight (Kg) / height (m 2 ) 

• BMI greater than or equal to 25 is overweight 

• BMI greater than or equal to 30 is obesity 


Classification 

BMI Classification 

WHO BMI cut 

offs 

Asians BMI cut 

offs 

Underweight = 23 

Pre-obese 25.0 – 29.99 22.9-24.9 

24 9 

Obese >= 30.0 >= 25.0 

Obese Class I 30.0 – 34.9 25- 29.9 

Obese Class II >= 35.0 >= 30.0 

Source: WHO 1998 , Western pacific region of WHO, 2000 


Health consequences of 

Obesity 

High blood pressure 

High cholesterol 

Diabetes 

Heart disease 

Stroke 

Gallbladder disease 

Osteoarthritis 

Obesity is not a simple problem for it can trigger at least 53 diseases 


Sleep apnea and respiratory problems 

Some cancers (endometrial, breast and 

colon) 

Liver disease 

Venous disease 

Acid reflux 

Menstrual irregularities and infertility 

Health repercussions of obesity, published in the Lancet, has revealed that “by 2030, 

non communicable disease will account for nearly 70% of all global deaths and 80% of 

these deaths will occur in developing countries like India” 


Bell the Fat” Anti obesity day: 

Nov 26” 

Multi-pronged strategy for 

• Effective weight management 

• Prevention of chronic diseases 

Secret to maintaining optimum weight. 

• Healthy lifestyle 

• Proper diet and exercise 


Weight management 

Weight gain 

Calories consumed > calorie used 

Weight loss 

Calories consumed < calorie used 

No Weight change 

Calories consumed = calorie used 

INPUT 

Calories 

from food 

OUTPUT 

Calories used 

during PA 

Balancing energy intake and energy expenditure is the 

basis of weight management throughout life 


Long-term strategies : 

Weight management 

Prevention 

Weight loss 

Weight maintenance 

Management of co-morbidities 


Weight loss goals 

Realistic 

Achievable 

Sustainable 

Strong 

Imperative 


How much weight loss 

NIH guidelines recommend a weight loss of 

500 grams – 1 kg /week 

Allow 6 months to achieve 10% weight loss 

After 6 months, focus should shift to weight 

maintenance for 6 months 


Lifestyle medicine: 

Need for change 

Use of lifestyle interventions in the 

treatment and management of lifestyle 

diseases. 

• Diet rectifications (Eat Low Fat, Low 

Salt, High Fiber Diet ) 

• Exercise ( Physical activity it ) 

• Stress management 

• Smoking cessation 

• Avoid alcohol 


Emphasis of lifestyle le medicine 

Assessing lifestyle 

Evaluating the risk factors 

Evaluating laboratory reports 

Discussing the opportunities for 

interventions 

Prescribing an optimal lifestyle 

Tracking and follow-ups 


Dietary interventions 

Managing g / preventing NCDs 


What is diet 

DIET is what We eat 

NUTRITION is what we Get from Diet 


Life style modification & Diet 

Balanced Diet 

Different foods 

Adequate quantity and proportions 

Carbohydrates, Fat, Proteins, 

Vitamins, Minerals, Fiber 

Energy source: 

•50% of from complex 

carbohydrates 

•15-20% from proteins. 

•25-30% from total fat. 

(Of this, saturated fat 

should be < 1/3 


Balanced Diet 

foods in quantities and proportions so that the 

need of calories, proteins, vitamins, i minerals 

and other nutrients is adequately met. 

• Includes a variety of foods from all the food groups. 

• Differ according to age, sex, physical activity and 

physiological i l status 

t 

The healthy combination is low fat, low refined carbohydrates, optimal amount of 

Vitamins, Minerals and fiber 




Total energy requirement 

Total energy requirement is a sum of : 

1. Basal metabolism 

2. Daily activities 

3. Occupation; 

expressed as RDA 

depends on Age, gender and physical work 


RDA for an 

Adult Sedentary Worker 

Gender Energy Protein Fat Calcium Iron 

(Kcal/d) (g/d) (g/d) (mg/d) (mg/d) 

Male 2320 60 25 600 17 

Female* 1900 55 20 600 21 

*Pregnancy +300 and lactation+550 and 400 

ICMR, 2010 


Diet for NCD: Main focus 

‣ Gradual weight loss. 

‣ Achieve & maintain the desirable body weight. 

‣ Correct eating habits. 

‣ Reduce the increased lipid levels. (CHD) 

‣ Meet the nutritional requirements 

‣ Reduce sodium intake (Hypertension) 

‣ Maintain blood sugar levels. (Diabetes) 


Foods promoting health 

Minimally processed grains 

Legumes 

Fiber rich foods 

Vegetables 

Fruits 

Foods of plant origin 


Promoting Healthy lifestyle 

le 

Traditional healthy diets 

Avoid tobacco, Alcohol 

Maintain i weight 

Daily physical activities 

Restrict foods high in sugar , refined starch and 

saturated and trans fats to children 


Dietary Guidelines for Indians 

ICMR 

‣ Consume nutritionally adequate diet through a 

wise choice from a variety of foods. 

‣ Additional food and extra care during pregnancy 

and lactation. 

‣ Exclusive breast-feeding. Breast – feeding can 

be continued up to two years with appropriate 

and adequate frequent supplements 

‣ Oils and animal foods in moderation, and restrict 

vanaspati /ghee/butter 

/b SIHFW: an ISO 9001: 2008 certified Institution 168

Strategies for Obesity Prevention 

ention 

For infants and young children: 

Promotion of exclusive breastfeeding 

Avoid use of added sugars and starches when 

feeding formula 

Instruct mothers to accept their child’s ability to 

regulate energy intake rather than feeding until 

the plate is empty 

Assure the appropriate micronutrient intake 

needed to promote optimal linear growth 


For children and adolescents 

Promote and active lifestyle 

Limit television viewing 

Promote the intake of fruits and vegetables 

Restrict the intake of energy dense , 

micronutrient poor foods (e.g. packaged 

foods) 

Restrict the intake of sugar sweetened soft 

drinks 


Tips for weight reduction 

Slow and steady 

Avoid severe fasting 

Achieve energy balance and appropriate 

weight for height 

Encourage physical activity 

Eat small frequent meals 

Cut down on sugar, salt, fatty foods and 

alcohol. 


Promote complex carbohydrates and fiber 

rich diets 

Increase consumption of fruits and 

vegetables, legumes, whole grains and nuts. 

Limit energy intake from total fat and shift 

from saturated to unsaturated 

Eliminate the use of trans fatty acids rich food 

products and sweets. 

Use low fat milk. 

Avoid fasting & feasting. 

Read the labels carefully. 


‣ Avoid fried foods and bakery products 

‣ Avoid organ meats like liver and brain, poultry with 

skin, higher fat meat cuts like hamburgers, bacon 

and sausages. 

‣ Avoid excessive alcohol, stop smoking 


The 5 “W” Plan 

1. What to eat 

2. When to eat 

3. Where to eat 

4. Why to eat 

5. Way to eat 

What you eat 

Have a balanced diet. 

Include micro and macro nutrients and fiber 

in adequate amounts 

Be careful about your fat intake. Avoid 

saturated fat. 

Restrict t salt and sugar intake. 


When to eat 

Set aside a time for breakfast ,lunch and 

dinner too. 

Have smaller meals at regular intervals. 

Never sleep immediately after your meals. 

Where to eat 

Decide one place in your house or office to 

eat food. 

While eating your meals, concentrate only 

on eating 


Why to eat 

Eat when you feel hungry 

Don not eat because you have nothing else to do 

Do not eat because you cannot say “NO” to 

anyone 


Way to eat 

Eat slowly. 

Chew properly. 

p Spend at least 15- 20 mins to complete 

your meals. 

Never drink water during your meals. 

Drink water 20 mts. after meals. 

stroll for about 15 mts. after meals 


Recommendations for cancer 

preventions 

entions 

Maintain weight / avoid weight gain 

Maintain Regular Physical activity 

Avoid alcohol 

Preserved foods and salt : Moderate consumption 

Minimal exposure to Alflatoxins in foods 

Diet with 400 gms of total fruits and vegetables 

Moderate consumption of preserved meats 

Do not consume food and drink at very hot 

temperature 


Recommendations in preventing 

diabetes 

Prevention / treatment of obesity 

Maintain optimum BMI 

weight reduction in overweight or obese individuals 

with impaired glucose tolerance 

Increase Physical activity 

Limit total fat intake : >10 % of the total energy 

intake 

NSP / dietary fibers : adequate amounts 


Recommendations in preventing CVDs 

Fats: restrict SFA (less than 10% of daily energy 

intake )Trans fatty acid( less than 1% of daily 

energy intake) 

Fruits and Veg. : 400-500 gms / day 

Sodium restriction

Calculating balanced diet 

Know Recommended Dietary Allowance 

(RDA) 

Menu Analysis 

Food Exchange List 


RDAs for an Adult 

Sedentary Worker 

Gender 

Energy 

Protein 

Fat 

Calcium 

Iron 

(Kcal/d) (g/d) (g/d) (mg/d) (mg/d) 

Male 2320 60 25 600 17 

Female* 1900 55 20 600 21 

*Pregnancy +300 ; lactation+550 

ICMR, 2010 


How to calculate balance diet 

Step I: Recommended Dietary Allowance 

(RDA) (specific for age, gender and 

activity). 

Step II: Menu Analysis 


Common Home Measures- 

Weight & Volume Equivalents 

1 Medium size bowl: 150-160 ml 

1 Table spoon (level): 15g or ml (approx) 

1 Table spoon (heaped): 20 g 

1 Tea spoon (level): 5g or ml 

1 Tea spoon (heaped): 7 g 

1 Medium size tea cup: 180-200 ml 

Big size glass/Cup: 250 ml 


Key recommendations -Diet 

• Fruit and vegetable intake 

• Unhealthy fats (Saturated fats 

e.g. Animal fats, milk products; 

transfats t – hydrogenated d oil) 

• Substitute with healthy fats 

• PUFA(poly) e.g. Fish oil; 

• MUFA(Mono) e.g. pea nut oil 

• Salt intake 

• Consumption of simple sugars 


Health Promotion through 

exercises 

Calorie consumption in different activities 

Activity Kcal/hr. Activity Kcal/hr. 

Cleaning 210 Gardening 300 

Watching TV 86 Cycling,15/h 360 

Running,12/hr 750 Walking4/hr 160 

Shuttle 348 Tennis 392 

TT 245 Dancing 372 

Typing 108 Sleeping 57 

Standing 132 Sitting 86 


Thank you 


Cancer 




Structure re of presentation 

Basic Understanding 

Common cancers 


Breast Cancer 

Screening of common cancer 

Case based discussions 

Prevention of cancer 

Palliative care 


Cancer – How old disease is 

Even in Bones of Dinosaurs 

Even in calcified mummies 


What is Cancer 


Cancer 

A group of diseases 

Uncontrolled cell multiplication 

Benign 

Malignant 


192

Growth of Cells 

• Undesirable 

• Uncontrolled 

• Unregulated 

• Useless 

• Harmful 

• Can invade 

Surrounding 

tissue 

Cancer - What Is It 


193

Determinants 

Tobacco- (Primary prevention possible) 

Occupational exposures 

Diet- 

high protein, low fiber, alcohol, Junk, 

Reproductive pattern influences 

Late marriage/ single 

pregnancy/Lactation 

Sexual practices and hygiene 

Life style, customs 

Viruses- 

Hepatitis-B virus/Human papilloma 

virus/CMV 


Common Cancer sites 

Male- 

• Mouth 

• Oro-pharynx 

• Stomach 

• Esophagus 

• Lungs 

Female- 

• Cervix 

• Breast 

• Mouth/Oro-pharynx 

• Esophagus 


Common cancers 

Lung 

Breast (women) 

Leukemias 

Blood stream 

Lymphomas: 

Lymph nodes 

Colon 

Bladder 

Prostate (men) 

sarcomas: 

Fat 

Bone 


Muscle 

196

Prefix 

adeno- 

chondro- 

Meaning 

Naming Cancer 

Cancer Prefixes Location 

gland 

cartilage 

erythro- 

red dblood cell 

hemangio- 

hepato- 

lipo- 

lympho- 

blood vessels 

liver 

fat 

lymphocyte 

melano- 

pigment cell 

myelo- 

myo- 

osteo- 

bone marrow 

muscle 

bone 


197

Global 

Source-WHO 

7.6 million deaths (13% of all deaths) in 

2008 

Tobacco is the most important risk factor 

for cancer 

Viral infections (HBV/HCV &HPV) 

responsible for 20% of cancer deaths 

Approx 70 % of cancer deaths occur in 

low- and middle-income countries. 

Projected-13.1 million deaths in 2030 


198

India 

0.8 million new cases/year 

2.4 million prevalent cases 

Tobacco Related Cancers (TRC) are 

amenable for primary prevention. 

48% cancers in men and 20% in women 

are due to tobacco. 

13% cancers of uterine cervix can be 

potentially screened and prevented 

9% of breast cancers can be detected early 

and treated effectively 

Source-WHO 


199


200

Five Common Cancers 

Rank World India 

Male 1 Lung Lung 

2 Stomach Lip 

3 Prostate t Oral Cavity 

4 Colon/Rectum Other pharynx 

5 Liver Esophagus 

Female 1 Breast Uterine Cervix 

2 Uterine Cervix Breast 

3 Colon/Rectum Ovary 

4 Lung Lip, Oral cavity 

5 Stomach Esophagus 


201

Dynamics of Cancer 

Increased Life expectancy 

Accuracy of Diagnosis 

Improved Life style 

Tobacco 

Alcohol 

Newer infections 

Environment-physical & social 

Diet 


202

Issues in Cancer control 

Burden of disease 

Poor/ unavailable diagnostic facility 

Awareness 

Trained manpower 

Competing priorities 

National guidelines- detection/therapy/ 

palliative 


203

Issues in Cancer control 

Early diagnosis-Individual /Clinic/ 

Community 

Therapy 

Palliative care-availability & level 

Nursing 

Service Delivery-DCCS/NGO/Private 


204

Cancer patterns 

Predominance of Tobacco related 

cancers 

Lung, oral , cervix and breast 

Increasing with decrease in 

communicable diseases 

Majority detected late 


205

Primary- 

Prevention and screening 

programs 


Specific protection 

‣implementation of tobacco control 

strategies, 

‣promotion of adequate and balanced dietary 

practices and reduction of alcohol intake. 

‣awareness 

‣risk factor modification. and Legislation 


206

Prevention ention and screening 

Secondary- 

Tertiary- 

Early Diagnosis & Treatment 

pap smear/ mammography 

Infrastructure for Chemotherapy/ 

Radiotherapy/Palliative 


207

Cancer control- strategies for 

primary prevention 

Awareness & education programs 

Role and use of media 

Community participation 

Combining with other programs 


208

Early diagnosis 

‣ Individual’s role 

• Reporting early 

• Self examination- 

Breast/Oral cavity 

• promoting genital hygiene 

and sexual behavior. 

• lifestyle l modification. 

‣ System’s role 

• Screening 


209

Common Risk factors and 

Screening for Cancers 

Cancer Risk factor Screening procedures 

Breast Age, parity, heredity Self examination 

Cervix Parity, age, multiple 

partners 

PAP smear 

Oral 

cancer 

Self examination, 

examination for 

leokoplakia 


210

Diagnosis 

Radiological 

Biochemical 

Endoscopy 

Pathological 

Immunological 


211

Treatment 

‣ Surgery 

‣ Radiotherapy 

‣ Chemotherapy 

‣ Palliative care 


212

Cancer 

Interventions in different 

Early 

Detection 

cancers 

Surgery Radiation Chemotherapy/ 

Hormonal 

adjuvant therapy 

Palliative 

Care 

Mouth/Pharynx + ++ +++ + +++ 

Esophagus - + ++ - +++ 

Stomach + + - - +++ 

Colon/Rectum ++ +++ ++ +++ +++ 

Liver - + - - +++ 

Lung - + ++ - +++ 

Breast +++ +++ ++ +++ +++ 

Cervix +++ ++ +++ - +++ 


Source-NCCP-Policies & Managerial Guidelines, WHO 2 nd Edition 2002 

213

Burden of Disease 


214

350 

Age wise distribution of 

deaths due to Cancer per 

100000 pop. 

311.3 309.2 

300 

250 

200 

150 

100 

50 

0 

8.2 

0-14 Years 15-59 Years 60+Years 

Source-WHO Organisation Mondiale de la Santé Department of Measurement and Health Information April 2011 


215

( 

Common Cancer (Female) 

120000 

100000 

80000 

101938 

103821 

87693 

90659 

Based on cancer registries 

across the country, cervix 

and breast cancers 

accounted for more than 

36% of cancer incidence in 

the country. 

60000 

40000 

20000 

29929 

30482 

14609 

14940 

18083 

18417 

0 

Cervix Breast Overy Oral cavity oesophagus 

Source: - National Health Profile, 2010 

2009 2010(Projected) 


216

Common Cancer in Male 

50000 

45000 

40000 

43576 

44301 

2009 2010(Projected) 

35000 

30000 

25000 

29474 

30921 

23433 

23281 

25408 

25831 

20000 

15000 

14366 14605 

10000 

5000 

0 

Oral cavity Lung Pharynx Oesophagus Stomach 

Source: - National Health Profile, 2010 


New Cancer Cases-India 

600 

500 

430.1 

518.8 

Male 

Female 

Tho ousands 

400 

300 

200 92.9 

105.5 

100 

10.2 

10.8 

0 

No of new cancer 

cases 

Age Standardised rate 

Risk of getting cancer 

before age75 ( %) 

Source- WHO (GLOBOCON 2008) 


218

No of Cancer Deaths -India 

350 

300 

321.4 

Male 

312.1 

Female 

250 

Tho ousands 

200 

150 

100 

71.2 

65.5 

50 

8 7.1 

0 

No of cancer Age Standardised Risk of dying 

deaths rate cancer before 

age75 ( %) 

Source- WHO (GLOBOCON 2008) 


219

Cancer-Rajasthan 

4500 

4000 

3340 

3500 

3000 

2275 

2500 

1710 

2000 1516 

4497 

2865 

Male 

Female 

1500 

1000 

500 

0 

246 184 180 183 

2007 2008 2009 2010 2011 (Till July) 

Source -DM&HS 


220

Cancer Deaths -Rajasthan 

60 

50 

40 

53 

Male 

Female 

40 

26 

30 

20 

26 

20 

15 

10 5 

4 

1 

1 

0 

2007 2008 2009 2010 2011 (Till July) 

Source -DM&HS 


221

10000 

District –wise Reported Cases 

of Cancer-Rajasthan 

Male 

Female 

4179 2522 

1000 

100 

10 

1 

14 

43 

15 34 12 

3 

4 

3 

2 

2 

01 0 10 0 

1 

0 

28 

22 

16 

8 

5 6 

2 

1 1 

55 

24 

12 

356 

361 

Source -DM&HS (Jan to July.2011) 


222

District wise Reported Cancer 

Deaths -Rajasthan 

District Male Female 


Jaipur 46 23 

Jalor 2 0 

Pali 2 2 

Jhalawar 2 0 

Total 53 26 

Source -DM&HS (Jan to July.2011) 


223

Age – wise distribution of 

Deaths due to Oral Cancer 

45 44 

45 

40 

35 

30 

25 

20 

15 

10 

5 

0 

02 0.2 

0-14 Years 15-59 Years 60+ Years 



224

Projected Cases of Oral Cancer in 

India 

Years Males Females 

Oral cancer 

Oral cancer 

Tongue Mouth Tongue Mouth 

2008 23932 28066 7687 14402 

2009 24330 29474 7829 14669 

2010 24735 30921 7974 14940 

2015 26590 38380 8689 16280 

Source: National Health Profile, 2009 


225

Management 

Patient with suspicious oral lesion 

(Self-respected or on examination) 

Clinical examination by Health professional 

Suspicious lesion 

Pre-malignant lesion 

Investigate for possibility of malignancy 

Malignant 

Refer for appropriate p treatment 

Not-Malignant 

Treat lesion 


226


Deaths due to Cervical Cancer 

45.3 

50 

45 

40 

35 

30 

25 

20 

15 

10 

5 

0 

27.5 

15-59 Years 60+ Years 



227

Stages of Cervical Cancer 


Symptoms of Cervical Cancer 

Post-menopausal bleeding 

Post-coital bleeding 

Inter menstrual bleeding 

Blood stained discharge per vaginum 

Excessive seropurulent discharge 

Backache 


229

Cusco's Speculum and Ayre's Spatula 


230

Evaluation and Management after 

Pap smear cytology 

PAP 

Normal 

Inflammation 

ASCUS/AGU 

S 

CIN/DYSPLA 

SIA 

Re-screen after 5 

yrs 

Repeat after 6 mths 

Colposcopy 

Normal 

Abnormal 

Normal & 

Satisfactory 

Abnormal 

Unsatisfactory 

Cryotherapy at the 

same sitting 

Normal 

Biosp 

y 

LEEP 

CIN 

LEEP 

Repeat PAP after 1 

YR 


Cryo therapy 

LEEP 

231

Visual Inspection using 4% Acetic 

acid (VIA): 

Acetic acid causes dehydration of the cells 

Surface coagulation of proteins reducing the 

transparency of the epithelium. 


232

VIA Category 

Negative 

Positive 

Criteria for Categorizing VIA Test 

Results 

Description 

•Noaceto-white lesions • Transparent lesions or faint patchy 

lesions without definite margins • Nabothian cysts becoming 

aceto-white • Faint line like aceto-whitening at the junction of 

columnar and squamous epithelium • Aceto-white lesions far 

away from the transformation zone. 

• Distinct, opaque aceto-white area • Margin should be well 

defined, may or may not be raised • Abnormality close to the 

squamocolumnar junction in the transformation zone and not 

far away from the os. 

INvasive 

Obvious growth or ulcer in the cervix. Acetowhite area may 

not be visible because of bledding. 


Evaluation and management 

after screening by VIA 

VIA 

Negative 

Positive 

Re-screen 

after 5 YRS 

Colposcopy 

PAP if available 

Normal & 

Satisfactory 

Abnormal 

Unsatisfacto 

ry 

Management 

Biospy 

LEEP 

LEEP 

Normal 

CIN 

Cryotherapy at 

the same 

sitting 

Repeat via after 1 

yr 

Cryotherapy 

LEEP 


234

Cryotherapy (ablation) 

Management 

Loop Electrosurgical Excisional procedure 

(LEEP) 

Cervical cancer can be treated 

‣Surgery 

‣Radiotherapy 

‣Chemotherapy 

‣CombinationC of the three 


235

Breast Cancer 

Second most common cancer among women 

Data from Hospital Based Cancer Registry 

(HBCR) show that only about 15% of patients 

present in localized stage. 


236


Deaths due to Breast Cancer 

31.6 

35 

30 22 

25 

20 

15 

10 

5 

0 

15-5959 Years 60+ Years 



237

Not modifiable: 

•Genetic family history 

•Age 

•Age at menarche 

Breast Cancer 

Risk 

Modifiable: 

•Diet 

•BMI 

•Exercise 

•Exogenous 

estrogen use 

•Alcohol 

h l 

consumption 

•Reproductive 

history 


Potentially 

modifiable 

•Age at first birth 

•Age at 

menopause 

•Breast feeding 

238

Sign and Symptoms 

A lump or thickening in or near the 

breast or in the underarm area 

Change in the size or shape of the 

breast 

Nipple turned inward 

Discharge (fluid) from the nipple, 

especially if it's bloody 

Dimpling or puckering in the skin of 

the breast 

Scaly, red, or swollen skin on the 

breast, nipple, or areola 


239

TNM Staging of Breast Cancer 

Primary Tumor Regional lymph nodes Distant metastases 

T x : Tumor cannot be 

N x : Cannot be assessed M 0 : No distant metastases 

assessed 

T 0 : No evidence of primary 

N 0 : No palpable regional 

lymph nodes 

M 1 : Presence of distant 

metastases 

tumor 

N 1: Palpable, mobile, 

T is : Carcinoma in situ 

T 1 : Tumor 2cm or less in its 

greatest t dimensioni 

lpsilateral axillary lymph 

node 

N 2 : Fixed ipsilateralil l axillary 

T 2 : Tumor 2-5cm. in greatest 

dimension 

lymph node 

N 3 : lpsilateral internal 

mammary/supraclavicular 

T 3 : Tumor>5cm. in greatest 

lymph nodes. 

dimension 

T 4 : Tumor of any size, with 

direct extension to 

SIHFW: An ISO:9001:2008 certified Institution 240 

240


Breast Examination by a 

Health Professional 

Patient lying down- look for any asymmetry in the 

breast 

With the flat of the hand, both the breasts are 

palpated in a circular manner starting from the 

nipple and areola in a clockwise manner towards 

the periphery and the axillary tail of the breast in 

sitting and lying down position. 

The axilla, supraclavicular region and liver are also 

examined 


Diagnosis 

Breast awareness & breast self 

examination 

Clinical Breast Examination (CBE) 

Mammography 


243

Management of Breast Cancer 

Patient with lump in breast 

(Detected by BSE) 

Clinical examination by a health 

professional 

Refer to higher centre for Investigation Reassure 

patient – all lumps need not be cancer 

Benigm lump 

Malignant lump Convey result to 

Reassure patient 

patient and support her to accept 

diagnosis 

Prompt referral and appropriate management 


Health professionals can – 

Key Messages 

‣ Create ‘Breast Awareness, 

‣ Offer Clinical Breast Examinations To Women 

Aged 40-69 Years 

‣ Reassure – All Lumps Are Not Cancer 

‣ Ensure Prompt Referral And Appropriate 

p 

Management 

‣ Provide pain relief and palliative care 


Lung Cancer 

Defined as a malignant tumour of the lung 

arising within the wall or epithelium of the 

bronchus. 

OR 

It is a disease which consists of uncontrolled cell 

growth in tissues of the lung . This growth may 

lead to metastasis 


246

Projected Cases 

of Lung Cancer in India 

50000 

45000 

428 863 

435 576 

443 301 

47 7623 

Male 

Female 

40000 

35000 

30000 

25000 

20000 

15000 

13009 

13250 

13494 

14705 

10000 

5000 

0 

2008 2009 2010 2015 

Source: National Health 

Profile, 2009 


247

Smoking 

Passive smoking 

Asbestos fibers 

Radon gas 

Familial predisposition 

Lung diseases 

Prior history of lung cancer 

Air pollution 

Causes 


248

Symptoms 

Persistent cough or worsening of an 

existing chronic cough blood in the sputum 

Persistent bronchitis or Repeated Respiratory 

infections 

Chest pain 

Unexplained weight loss 

Fatigue 

Breathing difficulties such as shortness of breath 

or wheezing 


249

Treatment and Staging NSCLC 

Stage Description Treatment Options 

Stage I a/b 

Tumor of any size is found only in 

the lung 

Stage II a/b Tumor has spread to lymph nodes 

associated with the lung 

Surgery 

Surgery 

Stage III a Tumor has spread to the lymph 

nodes in the tracheal area, 

Chemotherapy 

followed by radiation or 

including chest wall and 

surgery 

diaphragm 

Stage III b Tumor has spread to the lymph Combination of 

nodes on the opposite lung or in 

the neck 

chemotherapy and 

radiation 

Stage IV Tumor has spread beyond the Chemotherapy and/or 

chest 

palliative 

(maintenance) care 


National Programme 


251

National Cancer Control Programme 

Established in 1975–76. 

76. 

Objectives 

‣ Primary prevention of tobacco related cancer 

‣ Secondary prevention i.e. early detection and 

diagnosis of cancers 

‣ Strengthening of existing cancer treatment 

facilities 

‣ Palliative care in terminal stage of the cancer 

At least 30% of the future cancer burden is potentially preventable by tobacco control 


252

National Cancer Registry Programme 

Initiated in 1982 by ICMR for data base of 

cancer cases 

Two types of registries: 

‣ Population Based Cancer Registry (21 ) 

‣ Hospital Based Cancer Registries (6) 

Data was collected from all cancer registries and 

all medical colleges for the “Development of an 

Atlas of Cancer in India” 

Cancer Awareness Day -7th November 


253

Year 

1975-76 

National Cancer Control Program was launched with priorities 

for equipping the premier cancer hospital/institutions 

1984-85 The strategy was revised and stress was laid on primary 

prevention and early detection 

1990-9191 District Cancer Control Program was started in selected 

districts (near the medical college hospitals) 

2000-20012001 Modified d District i Cancer Control program initiatedi i 2004 Evaluation of NCCP was done by National Institute of Health 

& Family Welfare, New Delhi. 

2005 The program was further revised after evaluation 

2012 National Programme for prevention and control of Cancer, 

Diabetes and Cardio Vascular Diseases (NPCDCS) 


Schemes under NCCP 

Recognition of New Regional Cancer Centers 

(RCCs) 

Strengthening of existing Regional Cancer Centers 

Development of Oncology Wing 

District Cancer Control Program 

Decentralized NGO Scheme 

Regional Cancer Centers 

Oncology wing 

District Cancer Control Program 

IEC Activities 


255

IEC Strategies 

Under NCCP IEC material used in the form of 

‣ Audio video spots 

‣ Posters 

‣ Leaflets 

‣ Flipcharts 


256



District 

Services under NCCP 

Health Promotion 

Home Care/ 

Early Detection 

at provider level 

Pain Relief/Palliative Care Treatment of 

common cancers 

Histopathology 

Endoscopy 


259

PHC 

Health education 


Home care 

Early detection 

Palliative care and pain relief 


260

Medical college 

Health Promotion & Home Care 

Early Detection ti & Treatment 

t 

Pain Relief/Palliative Care 

Training of Health personals 

Early detection/ Registration/ mobile units 

Radiotherapy with cobalt-60 units 

Diagnosis i and staging by clinical/ 

i l/ 

histopathological/ biochemical/ radiological/ 

endoscopic/ immunological/ isotope 


261

Regional cancer centre 

Health Promotion 

Home Care 

Early Detection 

Pain Relief/Palliative 

Care/Comprehensive Cancer treatment 

Organize screening programme/Cytology 

training/ 

Basic and applied research/Training of all 

categories of personnel 

Cancer Registries 

Epidemiology 


262

Why include Cancer In NPCDCS 

No uniform cancer preventionention strategy 

No education on risk factors, early warning 

signals and their management 

Cancer screening is not practiced in an organized 

fashion 

Diagnostic infrastructure is limited 


263


NPCDCS formed after merging the NCCP 

&NPDCS 

Provide technical & financial support to 65 Health 

care centers. 

These centers are known as “Tertiary Cancer 

Center” (TCC) 

NPCDCS has two component: 

‣ Cancer 

‣ Diabetes,CVD & Stroke 

Total 22 cancer drugs are prescribed under NPCDCS guidelines 


264

Objective e of TCC Scheme 

Develop regional referral cancer centers to 

provide specialized and comprehensive cancer 

care, 

Provide training and research facilities in an all 

types of cancer with focus on Oral, Cervix & 

Breast Cancer 


265

Financial Assistance For Cancer 

Component Under NPCDCS 

Yearly (Rs lakhs) 

District cancer care facility 166.42 

District NCD Cell 21.44 

State NCD cell 23.48 

• Financial assistance of Rs 6 crores for procurement of 

equipment, Construction of building & HR recruitment 

is provided 

•Central & State share will be 80 :20 


266

Thank You 

For more details log on to 

www. Sihfwrajasthan.com 

or 

contact : Director-SIHFW on 

sihfwraj@yahoo.co.in 


267

Cerebro-vascular accidents: 

Stroke 




268

Definition 

‣ Group of brain dysfunctions related to disease 

of the blood vessels supplying the brain. 

‣ Include diseases of the vascular system thatt 

causes 

• Ischemia 

• Infarction of the brain 

• Spontaneous hemorrhage into the brain 

• Subarachnoid space. 


269

Cerebrovascular Accident 

25% with initial stroke die within 1 year 

50-75% will be functionally independent 

25% will live with permanent disability 

Physical, cognitive, emotional, & financial impact 


270


7000000 

6000000 

5802295 

5289357 6368970 

5000000 

4818740 

4000000 

3000000 

2000000 

1000000 

792628 593362 

930985 

639455 

1998 

2004 

0 

No. of cases No.of deaths No. of YLL No. of DALY 

Figure: - Burden of stroke, 2004. Source:-Assessment of Burden of NCD, ICMR, 2006 


271

Epidemiological Determinants 

‣ Hematologic disorders 

‣ Embolism from arterial 

‣ Athero Thromboembolism 

‣ Trauma 

‣ Fibro muscular dysplasia 

‣ Congenital 

arterial 

anomalies 

aneurysm 

‣ Inflammatory 

disease 

vascular 

‣ Excessive irradiation of the 

head and neck 

‣ Dementia 

‣ Cerebral infarction and 

ischemia 

‣ Occlusion or stenosis 


272

Risk Factors 

‣ Age and Sex 

‣ Hypertension and 

Cardiac diseases 

‣ Atrial fibrillation (AF) 

‣ Coronary artery disease 

‣ Oral contraceptive use 

‣ Transient ischemic 

attacks 

‣ Blood viscosity 

‣ Smoking/ Alcohol 

‣ Lipids and Obesity ‣ Diabetes Mellitus 


273

CV Accident: 

Risk Factors 

Non-modifiable: 

Age – Occurrence doubles each decade >55 

years 

Gender – Equal for men & women; women die 

more frequently than men 

Race – African Americans, Hispanics, Native 

Americans, Asian Americans -- higher 

incidence 

Heredity – family history, prior transient 

ischemic attack, or prior stroke increases risk 


274


Risk Factors 

Controllable Risks : 

High blood pressure Diabetes 

Cigarette smoking TIA (Aspirin) 

High blood cholesterol Obesity 

Heart Disease Atrial 

fibrillation 

Oral contraceptive use Physical 

inactivity 

Sickle cell disease Asymptomatic 

carotid stenosis 

Hypercoagulability 


275

CVA – Risk Factors 


276


Anatomy of Cerebral Circulation 

 

 

 

Blood Supply 

20% of cardiac output—750- 

1000ml/min 

>30 second interruption– neurologic 

metabolism is altered; metabolism 

stops in 2 minutes; brain cell death < 5 

mins. 


277


278

Ischemic Cascade 


Series of metabolic events 

Pathophysiology 

h Inadequate ATP adenosine triphosphate production 

Loss of ion homeostasis 

Release of excitatory amino acids – glutamate 

Free radical formation 

Cell death 

Border Zone (ischemic penumbra): reversible area that 

surrounds the core ischemic area in which there is reduced 

blood flow but which can be restored (3 hours +/-) 


279

Atherosclerosis: 

Thrombus formation & emboli development 

Abnormal filtration of lipids in the intimal layer of the 

arterial wall 

Plaque develops & locations of increased turbulence of 

blood - bifurcations 

Increased turbulence of blood or a tortuous area 

Calcified plaques rupture or fissure 

Platelets & fibrin adhere to the plaque 

Narrowing or blockage of an artery by thrombus or emboli 

Cerebral Infarction: blocked artery with blood supply cut 

off beyond the blockage 


280

‣ Trouble in walking 

Symptoms 

‣ Altered movement coordination and 

disequilibrium 

‣ Sudden confusion or trouble in speaking or 

understanding. Weakness of facial 

muscles causing drooling. 

‣ Dysarthria 

‣ Apraxia 


281

‣ Sudden trouble in seeing with ihone or both 

eye, troubled walking, dizziness, loss of 

balance or coordination 

‣ Aphasia 

‣ Visual field defect 

‣ Memory deficits 

‣ Disorganized thinking, confusion, 

hypersexual gestures 

‣ Anosognosia 

‣ Altered smell, taste, hearing, or vision 


282

Identification of an acute 

event 

 

Sudden numbness or weakness of face, arm, or 

leg, especially on one side of the body. 

 

Sudden onset of inability or difficulty in speech 

Sudden loss of consciousness. 

 

Sudden onset of blindness in or both eyes. 

Sudden onset of imbalance. 

 

Sudden severe headache h with no known cause. 

Seizure 


283


Transient Ischemic Attack 

Temporary focal loss of neurologic function 

Caused by ischemia to one of the vascular territories of the 

brain 

Microemboli with temporary blockage of blood flow 

Lasts less than 24 hrs – often less than 15 mins 

Most resolve within 3 hours 

Warning sign of progressive cerebrovascular disease 


284

Diagnosis: 

CT without contrast 


Transient Ischemic Attack 

Confirm that TIA is not related to brain lesions 

Cardiac Evaluation 

Rule out cardiac mural thrombi 

Treatment: 

Medications that prevent platelet aggregation 

ASA-300mg st followed by 150mg/day, Clopidogrel- 

300mg loading, then 75mg daily. 

Oral anticoagulants 


285


Classifications 

Based on underlying pathophysiologic findings 


286



Ischemic Stroke 

Thrombotic 

Embolic 

Hemorrhagic Stroke 

Intracerebral Hemorrhage 

Subarachnoid Hemorrhage 

 

Aneurysm 

Berry or Saccular 


287



Ischemic Stroke—inadequate blood flow to the brain from 

partial or complete occlusions of an artery--85% of all strokes 

• Extent of a stroke depends on: 

Rapidity of onset 

Size of the lesion 

Presence of collateral a circulationcu • Symptoms may progress in the first 72 hours as infarction & 

cerebral edema increase 

Types of Ischemic Stroke: 

Thrombotic Stroke Embolic Stroke 


288

CVA Recognition 


289


Ischemic – Thrombotic Stroke 

Lumen of the blood vessels narrow – then 

becomes occluded – infarction 

Associated with HTN and Diabetes Mellitus 

>60% of strokes 

50% are preceded by TIA 

Lacunar Stroke: development of cavity in place 

of infarcted brain tissue – results in considerable 

deficits – motor hemiplegia, contralateral loss of 

sensation or motor ability 


290


Thrombotic Stroke 


291


292


Common Sites of 

Atherosclerosis 


293


294



Ischemic – Embolic Stroke 

Embolus lodges in and occludes a cerebral artery 

Results in infarction & cerebral edema of the area supplied 

by the vessel 

Second most common cause of stroke – 24% 

Emboli originate in endocardial layer of the heart – atrial 

fibrillation, MI, infective endocarditis, rheumatic heart 

disease, valvular prostheses 

Rapid occurrence with severe symptoms – body does not 

have time to develop collateral circulation 

Any age group 

Recurrence common if underlying cause not treated 


296


Embolic Stroke 


297


Goals for Management 

Immediate – assess & stabilize 

• ABCs, 

• Oxygen if hypoxic 

• IV access 

• Check glucose 

• 12-lead EKG 


298


Goals for Management 

CT Scan – No hemorrhage: 

• Consider Fibrinolytic therapy 

Check for exclusions 

tPA 

• No anticoagulants or antiplatelet therapy for 24 hours 

• If not a candidate: Antiplatelet Therapy 

CT Scan – Hemorrhage: 

• Neurosurgery 

• If no surgery: Stroke Unit 

Monitor BP and treat Hypertension 

Monitor Neuro status 

Monitor blood glucose and treat as needed 

Supportive therapy 


299




15% of all strokes 

Result from bleeding into the brain tissue 

itself 

Intracerebral 

Subarachnoid 


300


Hemorrhage Stroke 


Rupture of a vessel 

Hypertension – most important cause 

Others: vascular malformations, coagulation 

disorders, anticoagulation, trauma, brain 

tumor, ruptured aneurysms 

Sudden onset of symptoms with progression 

Neurological 

deficits, headache, nausea, vomiting, decreased 

LOC, and hypertension 

Prognosis: poor – 50% die within weeks 

20% functionally independent at 6 months 


301


Hemorrhage Stroke 



302


303


Hemorrhagic-Subarachnoid 

Hemorrhagic Stroke–Subarachnoid S Hemorrhage 

Intracranial bleeding into the cerebrospinal fluidfilled 

space between the arachnoid and pia mater 

membranes on the surface of the brain 


304



Commonly caused by rupture of cerebral aneurysm 

(congenital or acquired) 

Saccular or berry – few to 20-30 mm in size 

Majority occur in the Circle of Willis 

Other causes: Arteriovenous malformation 

(AVM), trauma, illicit drug abuse 

Incidence: 6-16/100,000 

Increases with age and more common in women 


305



Cerebral Aneurysm 

Warning Symptoms: sudden onset of a severe 

headache – “worst headache of one’s life” 

Change of LOC, Neurological 

deficits, nausea, vomiting, seizures, stiff neck 

Despite improvements in surgical techniques, many 

patients die or left with significant cognitive difficulties 


306

Delayed Neurological deficit in 

Rerupture 

Vasospasm 

Hydrocephalus 

Hyponatremia 

SAH 


307

Surgical Treatment: 


Cerebral Aneurysm 

Clipping the aneurysm – prevents rebleed 

Coiling – platinum coil inserted into the lumen of the 

aneurysm to occlude the sac 

Postop: Vasospasm prevention – Calcium Channel 

Blockers 


308


309


Cerebral Aneurysm – Surgical 

Tx 


310


Cerebral Aneurysm – Coiling 


311

Cerebrovascular Accident Classification 

Type Gender/Age Warning Time of Onset Course/Prognosis 

Ischemic 

Thrombotic 

Men more than 

women, oldest 

median age 

TIA (30%- 

50% of 

cases) 

During or after 

sleep 

Stepwise progression, signs 

and symptoms develop slowly, 

l 

usually some improvement, 

recurrence in 20%-25% of 

survivors 

Embolic 

Men more than 

TIA 

Lack of 

Single event, signs and 

women 

(uncommon) relationship to 

activity, sudden 

onset 

symptoms develop quickly, 

usually some improvement, 

recurrence common without 

aggressive treatment of 

underlying disease 

Hemorrhagic 

Intracerebral 

Slightly higher in 

women 

Headache 

(25% of 

cases) 

Activity (often) 

Progression over 24 hr; poor 

prognosis, fatality more likely 

with presence of coma 

Subarachnoid Slightly higher in 

women, youngest 

median age 

Headache 

(common) 

Activity (often), 

sudden onset 

Most commonly 

Single sudden event usually, 

fatality more likely with 

presence of coma 

related to head 

trauma 

TIA, Transient ischemic attack SIHFW: An ISO:9001:2008 certified Institution 

SIHFW: An ISO:9001:2008 certified Institution 312 312


Clinical i l Manifestations 

i 

Middle Cerebral Artery Involvement 

Contralateral weakness 

Hemiparesis; hemiplegia 

Contralateral hemianesthesia 

Loss of proprioception, fine touch and localization 

Dominant hemisphere: aphasia 

Nondominant hemisphere – neglect of opposite side; 

anosognosia – unaware or denial of neuro deficit 

it 

Homonymous hemianopsia – defective vision or blindness 

right or left halves of visual fields of both eyes 


313


Clinical Manifestations 

Anterior Cerebral Artery Involvement 

Brain stem occlusion 

Contralateral 

weakness of proximal upper extremity 

sensory & motor deficits of lower extremities 

Urinary incontinence 

Sensory loss (discrimination, proprioception) 

Contralateral grasp & sucking reflexes may be present 

Apraxia – loss of ability to carry out familiar purposeful 

movements in the absence of sensory or motor impairment 

Personality change: flat affect, loss of spontaneity, loss of 

interest in surroundings 

Cognitive impairment 




Posterior Cerebral Artery & 

Vertebrobasilar Involvement 

Alert to comatose 

Unilateral or bilateral sensory loss 

Contralateral or bilateral weakness 

Dysarthria – impaired speech articulation 

Dysphagia – difficulty in swallowing 

Hoarseness 

Ataxia, Vertigo 

Unilateral hearing loss 

Visual disturbances (blindness, homonymous 

hemianopsia, nystagmus, diplopia) 




Right Brain – Left Brain Damage 


316


317


318


Treatment Goals 

Prevention – Health Maintenance Focus: 

Healthy diet 

Weight control 

Regular exercise 

No smoking 

Limit alcohol consumption 

Routine health assessment 

Control of risk factors-BP, Hyperglycemia, 

hyperlipidemia 


319



Prevention 

Drug Therapy 

Surgical Therapy 

Rehabilitation 


320


Diagnostic Studies 

Done to confirm CVA and identify cause 

PE: Neuro Assessment; Carotid bruit 

Carotid doppler studies (ultrasound study) 

CT – primary – identifies size, location, differentiates 

between ischemic and hemorrhagic 

CTA – CT Angiography – visualizes vasculature 

MRI – greater specificity than CT 

May not be able to be used on all patients 

(metal, claustrophobia) 

Angiography: gold standard for imaging carotid arteries 


321


Treatment t Goals 

Drug Therapy – Thrombotic CVA – to reestablish blood 

flow through a blocked artery 

Thrombolytic Drugs: tPA (tissue plasminogen activator) 

produce localized fibrinolysis by binding to the fibrin in 

the thrombi 

Plasminogen is converted to plasmin (fibrinolysin) 

Enzymatic action digests fibrin & fibrinogen 

Results is clot lysis 

Administered within 3 hours of symptoms of ischemic CVA 

Confirmed DX with CT 

Patient anticoagulated 

ASA 


322

CVA 

- Treatment Goals 

Surgical Treatment 

Carotid endarterectomy – preventive – > 

100,000/year 

Removal of atheromatous lesion 

Clipping, wrapping, coiling Aneurysm 

Evacuation of aneurysm-induced hematomas larger 

than 3 cm. 

Treatment of AV Malformations 


323

Carotid Endarterectomy 


324

Drug Therapy 



Measures to prevent the development of a 

thrombus or embolus for “At Risk” patients: 

Antiplatelet Agents 

Aspirin 

Clopidogrel 

Combinatio 

Oral anticoagulation i – Coumadin 

Treatment of choice for individuals with atrial 

fibrillation who have had a TIA 


325


Acute Phase 

Patient Education: 

Clear explanations for all care/treatments 

Focus on improvements—regained i abilities 

Include family 


326



Comprehensive plan – 

Physical Medicine & Rehabilitation 

Learn techniques to self-monitor & maintain physical 

wellness 

Avoid complications of stroke 

Communication 

Maintain nutrition & hydration 

Use community resources 

Family cohesiveness 


327


328

Cardio-Vascular Diseases 


329

Introduction 

Cardiovascular disease (CVD) includes 

dysfunctional conditions of- 

Heart, 

Arteries and 

Veins 


330

Source: WHO 


Number one cause of death globally: more 

people die annually from CVDs than from 

any other cause 

17.3 million people died from CVDs in 2008 

30%of all global deaths 

7.3 million - coronary heart disease 

6.2 million – stroke 

By 2030, almost 23.6 million people will die 

from CVDs, mainly from heart disease and 

stroke. 


331

Estimated cases of CHD in India 

40000000 

35000000 

25430046 

36092297 

30000000 

25000000 

20000000 

15000000 

10000000 

24688119 

22286577 

18007899 

14740808 

17878889 

12300104 

Rural 

Urban 

5000000 

0 

2000 2005 2010 2015 

Source: - NCMH Burden of Diseases in 

India, 2005 


332

Cardiovascular Diseases 

group of disorders of the heart and blood vessels, 

and include: 

‣ Coronary heart disease 

‣ Cerebrovascular disease 

‣ Peripheral arterial disease 

‣ Rheumatic heart disease 

‣ Congenital heart disease 

‣ Deep vein thrombosis and pulmonary embolism 

‣ Heart attacks and strokes 


333

Risk 

Factors 

High 

cholesterol 

High BP 

Diabetes 

Obesity 

Smoking 

Ageing 

Consequen 

ce 

Stiff Arteries 

Results 

Heart 

Attack 

Stroke 

Heart 

Failure 


334

Newly emerging 

CVD risk factors 

‣ Low birth weight 

‣ Folate deficiency 

‣ Infections 


335

WHO CVD-Risk Management 

Package 

Designed primarily for the management of 

cardiovascular risk in individuals detected 

to have hypertension through opportunistic 

screening includes 

‣Conditions that characterize the three 

scenarios 

‣Skill-level level of the health worker 

‣Diagnostic and therapeutic facilities 

‣Available health services 


336

Resource Scenario-1 Scenario-2 Scenario-3 

required 

Human 

resource 

Health worker Medical 

Doctor or 

Medical doctor with 

specialist care 

Nurse 

Equipments Stethoscope 

BP 

Stethoscope 

BP instrument 

t 

Stethoscope 

BP instrument 

t 

instrument 

Measuring 

Measuring 

tape 

Measuring tape 

Weighing scale 

tape 

Weighing 

scale 

Weighing 

scale 

Test tubes 

ECG machine 

Ophthalmoscope 

Blood chemistry 

Test tubes Burner analysis support 

Burner Strips for urine Test tubes 

Strips for 

sugar and 

Burner 

urine sugar albumin Strips for urine sugar 


Generic 

drugs 

Thiazide 

diuretics 

Thiazides 

Angiotensin 

Thiazides 

Angiotensin 

converting 

Metformin(o 

ptional) 

converting 

enzyme 

inhibitors 

enzyme inhibitors 

Calciumchannel blockers 

Betablokers 

Calcium 

channel 

Aspirin 

Insulin 

blockers 

Betablokers 

Aspirin 

Metformin 

Glibenclamide 

Statins (cost) 

Metformin Angiotensin blockers 

(cost) 

Other 

Referral 

Referral 

Specialist care 

facilities Maintenance Maintenance Maintenance 

& Calibration & Calibration &Calibration of BP 

of BP of BP instrument 

instrument instrument 


338

Prevention of CVD 

Heart disease and stroke can be 

prevented through- 

Healthy diet 

Regular physical activity 

Avoiding tobacco smoke 

A diet rich in Nuts, fruit and vegetables 

Maintaining i i a healthy body weight 


339

Hypertension 


340

Hypertension 

“ high blood pressure“ 

A chronic medical condition in 

which the systemic arterial blood 

pressure is elevated. 


341

Introduction 

Abnormally elevated blood pressure is a 

pathological l condition which h increases the 

work load on the heart. This condition is 

termed as high blood pressure or hypertension. 

Hypertension doubles the risk of 

CAD, CHF, ischemic and hemorrhagic 

stroke, renal failure and PAD 

Based on the etiology, high blood pressure is 

of two types: 

• Primary/essential 

• Secondary 


342

Classification 

Primary / Essential hypertension 

‣No medical cause found. 

‣90–95% 95% of cases relate to it. 

Secondary hypertension 

‣Caused by identified conditions affecting 

kidneys, arteries, heart, or endocrine 

system.

Primary V/s secondary 

Primary 

‣ More Common 

‣ Gradual :in onset 

‣ Age: Affects after 40 

‣ Strong Family History 

‣ Cause Premature 

Artherosclerosis 

‣ Is life long 

Secondary 

‣ Less common 

‣ Dramatic in onset 

‣ Age:1 st 2 nd Decade/5 th 

6 th decade 

‣ F.H: May/may not be 

present 

‣ Causes: Endocrine tumor 

‣ Chronic steroids 

‣ May/or may not resolve 


344


Risk/ trigger factors 

‣ Stress 

‣ Potassium deficiency i & sodium sensitivity 

‣ Alcohol intake 

‣ Vitamin D deficiency 

‣ Obesity/metabolic disorder 

‣ Sedentary lifestyle and Smoking 

‣ Pre-eclampsia during pregnancy 


345

Secondary Causes 

of fHypertension 

Chronic kidney disease – 

CRF, PCKD, obstructive ti uropathy 

Drug-induced or related causes 

Primary aldosteronism 

Renovascular disease – 

atherosclerotic, fibromuscular dysplasia 

Chronic steroid therapy and Cushing’s 

syndrome 

Pheochromocytoma 

Coarctation of the aorta 

Thyroid or parathyroid disease 

 

Sleep apnea 


346

Symptoms 

‣ Headache 

‣ Drowsiness 

‣ Confusion 

‣ Vision disorders 

‣ Nausea and 

‣ Vomiting 


347

Drug-Induced Hypertension: 

Prescription Medications 

Steroids 

Estrogens 

NSAIDS 

Phenylpropanolamines 

Cyclosporine/tacrolimus 

Erythropoietin 

Sibutramine 

Methylphenidate 

h 

t 

Ergotamine 

Ketamine 

Desflurane 

Carbamazepine 

Bromocryptine 

Metoclopramide 

Antidepressants 

• Venlafaxine 

Buspirone 


348

Criteria for diagnosing high blood 

pressure 

Category Systolic Diastolic 

Normal Less than 120 Less than 80 

Pre-hypertension 120-139 80-89 

High Blood 

Pressure 

Stage 1 140-159159 90-9999 

Stage 2 160 or higher 100 or higher 

Source: JNC VII classification SIHFW: An ISO:9001:2008 certified Institution 349

Management of 

Hypertension 

1. Assessment of medical history 

2. Physical Examination 

3. Laboratory Investigation 


350

Headache (severe hypertension) < morning in 

occipital region 

Dizziness, palpitations, easy fatigability 

Ask for: 

1Ri 1.Risk kfactors 

Lack of physical activity (or sedentary 

lifestyle). 

Obesity or being overweight 

Abdominal obesity 

 

High sodium intake/high salt intake 

Excess alcohol consumption 


351

2.Family history 

3.Symptoms of consequences of 

hypertension 

4.Frequent intake of pain relieving drugs 

(NSAIDS) 

5.Steroid intake for asthma 

6.Breathing difficulty particularly on 

exertion 

7.Swelling of feet 

8.Urinary difficulties, history of passing 

stones in the past 


352

Physical examination should include 

• Pulse rate 

• Palpating all peripheral pulses 

• BP measurement at least in one upper and 

one lower limb 

• Assessment of BMI (Body weight and height to 

obtain BMI 

• Measurement of Waist circumference 

• Palpation of neck for enlarged thyroid 

• Auscultation for bruit (renal, carotid, abdominal 

and others) 

• Eye evaluation if ophthalmology facility is 

available 


353

Essential: 

i.Blood Sugar 

ii.Urine Ui analysis for proteinuria 

i 


354

Desirable: 

(at CHC/sub-district/district level hospitals 

depending upon the available facilities for 

laboratory investigations) 

I. Haemogram, 

II.Serum creatinine 

III.Serum sodium, potassium and calcium levels 

IV.Lipid profile 

V.Complete Urine analysis 

VI.Electrocardiogram(ECG) 

VII.X-Ray chest 

VIII.Thyroid function test 


355

‣ Therapeutic life-style management 

‣ Drug Therapy 


356

Life style advice is advocated for the first six month 

after the diagnosis of high BP in the following 

situations: 

If the BP is less than 160/100 mm of Hg 

There is no diabetes, co-existing heart disease 

stroke or peripheral vascular disease 

No evidence of LVH on ECG 

Absence of urinary proteinuria and 

Serum creatinine

Weight reduction 

Dietary salt reduction 

Lifestyle modifications to 

manage hypertension 

Attain and maintain BMI


The aim should be to get to blood pressure 

levels of less than 120/80 mms of Hg 

without t bothersome side-effects. 

Don't accept blood pressure levels of 

140/90 mms of Hg or more 

Maintain healthy blood pressure throughout 

the person’s lives 

Prevent and control risk factors which could 

give rise to high blood pressure. 

Always make sure that risk factors are 

controlled. 

Prevent and control risk factors which could 

increase risk of complications due to high 

blood pressure. 


359

Pharmacologic therapy 

Diuretics 

Ace inhibitors/ARB’s 

Aldosterone antagonists 

Beta blockers 

Calcium channel blockers 

α-adrenergic blockers 

Sympatholytic agents 

Direct vasodilators 


360

Diuretics 

Thiazide Inhibit Na + /Cl - pump in DCT 

 

 

 

Hydrochlorthizide 6.25-50mg/day (1-2) 

Chlorthalidone 25-50mg/day (1) 

• C/I 

Diabetes, dyslipidemia, hyperuricemia, Gout, hypokalemia 

Loop diuretics 

Furosemide 40-80mg/day (2-3) 

• C/I 

Diabetes, dyslipidemia,hyperuricemia, gout, hypokalemia 

Aldosterone antagonists 

Spironolactone 25-100mg/day (1-2) 

Eplerenone 50-100mg/day (1-2) 

• C/I Renal failure, hyperkalemia 

K + retaining 

Amiloride 

5-10mg/day(1-2) 

Triamterene 

50 –100mg/day(1-2) 

• C/I Renal failure, hyperkalemia 


361

o 

o 

o 

o 

ACE inhibitors 

Decrease production of angiotensin i II, thus causing 

efferent arteriolar vasodilatation 

o Enalapril 5-40mg/day(1-2) 

o 

Captopril 25-200mg/day(2) 

200mg/da o Lisinopril10-40mg/day (1) 

o Ramipril 2.5-20mg/day(1-2) 

Can be combined with diuretics and CCB 

Side effects-Dry cough, Angioedema, Hyperkalemia 

ARB’s 

o Losartan 25-100mg/day (1-2) 

o Valsartan 80-320mg/day(1) 

o Candesartan 2-32mg/day (1) 

o Telmisartan 20-80mg/day(1) 

o Olmisartan 20-40mg/day(1) 

C/I of ACEI’s and ARB’s are renal failure, bilateral 

renal artery stenosis, pregnancy 


362

Beta blockers 

Act by decreasing cardiac output, due to reduction of heart rate 

and contractility 

Selective (ß1) 

Acebutolol-200-600mg/day(2) 

Atenolol-50-100mg/day(1) 

Metoprolol-12.5-100mg/day(2) 

Bisoprolol-10mg/day(1) 

Esmolol-50-300µg/kg/min IV 

Nonselective 

Propranolol-40-160mg/day(2) 

Combined alpha/beta 

Labetalol-200-800mg/day(2) 

Carvedilol-12.5-50mg/day(2) 

Contraindications are asthma, COPD, PR-

Calcium channel blockers 

Reduce vascular resistance through L channel 

blockade, which reduces intracellular Ca and 

causes vasodilatation 

ti 

Dihydropyridines 

Amlodipine-5-10mg/day 

Felodipine-5-10mg/day 

Nicardipine-20-40mg tid 

Nifedipine(LA)-30-60mg/day(1) 

Nondihydropyridines 

Diltiazem-30-80mg qid 

Diltiazem(LA)-180-420mg/day(1) 

(1) 

Verapamil-40-160mg tid 

Side effects are flushing, headache, pedal 

edema 


364

α adrenergic blockers 

Lower BP by decreasing peripheral vascular 

resistance 

• Selective 

Prazosin 2-20mg/day (2-3) 

Doxazosin 1-16mg/day(1) 

Terazosin 1-10mg/day(1-2) 

• Nonselective 

Phenoxybenzamine 20-120mg/day(2-3) 


365

Sympatholytic agents 

Decrease peripheral resistance by inhibiting 

sympathetic outflow 

• Clonidine 01-0 0.1-0.6mg/day(2) 

• Methyldopa 250-1000mg/day(2) 

• Reserpine 0.05-0.25mg/day(1) 

Usefulness is limited it by dryness of mouth, orthostatic 

t ti 

hypotension, sexual dysfunction, sedation and 

numerous drug-drug interaction 

Direct vasodilators 

Reduce peripheral resistance 

• Hydralazine 25-100mg/day(2) 

• Minoxidil 25-80mg/day(1-2) 

Hydralazine- may cause lupus –like syndrome and 

minoxidil may cause hirsutism and pericardial effusion 


366

Medicines are tailored depending on the following 

factors 

1. Blood pressure level 

2. Patient characteristics (like age, body weight, 

occupation) 

o 3. Co-existing risk factors 

4. Type and extent of target organ damage 

5. Other associated diseases 

6. Affordability 


367

‣ diuretics (hydrochchlorthiozide), calcium channel 

blockers (amlodipine) and ACE inhibitors (Enalapril) 

are relatively cheap. 

‣ Drug therapy should be started in individuals at the 

time of diagnosis if they have blood pressure more 

than 160/100mmHg (despite non-pharmacological 

interventions) 

‣ or if BP>140/90 in diabetic subjects or end organ 

damage such as proteinurea, high blood urea, ECG 

evidence of left ventricular hypertrophy, presence of 

heart diseases and evidence of retinopathy. In all other 

individuals life style modification should be tried for at 

least six months before initiating drug therapy. 


368

‣ Start with calcium channel blockers (specifically if the 

person is older than 55 years) and 

‣ ACE inhibitors if less than 55 years. Recheck the BP 

in 2 weeks. If BP is not under control adding diuretics 

(Hydrochlorothiazide 12.5 mg a day) may be helpful. 

Normally this should bring the BP under control. 

‣ If the BP is not controlled by the combination of 

Amlodipine 10mg +Hydrochlorothiazide 25mg aday 

or Enalapril 10mg and Hydrochlorothiazide 25mg a 

day, a referral to a higher center may be necessary. 


Treatment of Hypertension 

Lifestyle Modifications 

Goal Blood Pressure (100 mmHg) 

2-drug combination for most 

(usually thiazide-type diuretic and 

ACEI, or ARB, or BB, or CCB) 

Not at Goal 

Blood Pressure 

Optimize dosages or add additional drugs 

until goal blood pressure is achieved. 

Consider consultation with hypertension specialist. 

Drug(s) for the compelling 

indications 

Other antihypertensive drugs 

(diuretics, ACEI, ARB, BB, CCB) 

as needed. 


Compelling Indications for 

Compelling Indication 

Individual Drug Classes 

Initial Therapy Options 

Diabetes 

ACEI, ARB, CCB, 

THIAZ, BB, 

Chronic kidney disease 

ACEI, ARB 

Recurrent stroke 

prevention 

THIAZ, ACEI 


371

Compelling Indications for 

Individual id Drug Classes 

Compelling Indication 

Initial Therapy Options 

Heart failure 

Postmyocardial 

infarction 

High CAD risk 

THIAZ, BB, ACEI, ARB, 

ARA 

BB, ACEI 

THIAZ, BB, ACEI, CCB 


372

Management of Hypertension at different levels of care 

Services 

Levels of Care 

Sec. care 

CHC PHC 

Screening for Hypertension √ √ √ 

Initial Risk Assessment 

Assessment of Medical History √ √ √ 

Physical Examination √ √ √ 

Laboratory Investigation 

Essential √ √ √ 

Desirable √ √ 

Therapeutic Lifestyle Management √ √ √ 

Pharmacotherapy 

Initiation (Uncomplicated cases) √ √ √ 

Initiation (Complicated cases) √ √ √ 

Follow-up √ √ √ 

Annual Assessment SIHFW: An ISO:9001:2008 certified Institution √ √ 

373 

√

Causes of Resistant Hypertension 

Resistant hypertension -BP persistently >140/90mmHg 

despite taking 3 or more agents including a diuretic, in 

reasonable combination and at full dose 

• Improper BP measurement 

• Excess sodium intake 

• Inadequate diuretic therapy 

• Medication 

Inadequate doses 

Drug actions and interactions: 

• Non-steroidal anti-inflammatory drugs 

(NSAIDs), illicit drugs, sympathomimetics, oral 

contraceptives 

Over-the-counter (OTC) drugs and herbal 

supplements 

• Excess alcohol intake 

• Identifiable causes of HTN 


374

Follow-up and Monitoring 

Patients should return for follow-up and 

adjustment of medications every 1-2 months until 

the BP goal is reached 

After BP at goal and stable, follow-up visits at 3- to 

6-month intervals 

• More frequent visits for stage 2 HTN or with 

complicating comorbid conditions 

• Continue to encourage self BP monitoring 

Serum potassium and creatinine monitored 1–2 

times per year 


375

Ischemic heart disease 


376

Ischemic Heart Disease 

Myocardial impairmenti due to 

imbalance between coronary blood 

flow and myocardial requirement. 


377

Cause 

‣ Atherosclerotic coronary artery disease 

‣ Imbalance between supply and demand 

in left ventricular ti hypertrophy 

h 


378

Burden of IH Disease 

10000000 22367840 

1000000 18600940 

10000 

463562 

554194 

16000808 

4952150 

14319427 

4461600 

100 

1 

No. of cases No. of deaths No.of YLL No.of DALY 

Source: Burden of Ischemic Heart Disease 2004 


379


‣ Heredity 

‣ High cholesterol 

‣ Tobacco 

‣ Obesity and High-fat diet 

‣ Hypertension 

‣ Diabetes 

‣ Physical inactivity 

‣ Emotional stress and Type A personality 

(impatient, aggressive, competitive) 


380

Symptoms 

‣ Abrupt, unexpected cardiac arrest. 

‣ Chest pain on exertion (angina pectoris), which 

h 

may be relieved by rest. 

‣ Shortness of breath on exertion & Irregular 

heartbeat. 

‣ Jaw/back/arm pain, especially on left side, 

either during exertion or at rest. 

‣ Palpitations 

‣ Dizziness, light-headedness, or fainting 

‣ Weakness on exertion or at rest 


381

Diagnosis 

Physical findings related to elevated BP, 

corneal arcus, Retinal arteriolar changes 

and aortic stenosis 

ECG monitoring 

Left ventricular Function assessment 

Coronary anatomy assessment 

Stress testing 

Echocardiography 


382

Treatment of IHD 

‣ Medical treatment ‣ Potassium channel 

‣ Interventional 

ti • Platelet inhibitors openers(Nicorandil 

• Lipid lowering agents 

) 

intervention 

• Beta blockers( 

Metoprolol,Atenolol) 

• Calcium channel 

blockers(Nifedipine,dil 

tiazem) 

• Estrogen 

replacement 

• Antioxidants 

• Gene therapy 

• Metabolic 

modulation 

• Percutaneous coronary 

• Surgical 

revascularization 

• Trans-myocardial laser 

revascularization 

• Spinal cord stimulation 

• Transcutaneous 

electric nerve 

stimulation 


383

Lifestyle modification for 

treatment of IHD 

‣ Cessation of smoking 

‣ Exercise 

‣ Diet 

‣ Alcohol 


384

Management & Prevention: 

Modifying the risk factors 

• High blood fats • Diabetes 

• LDL 

• Hypertension 

• Obesity 

• Triglycerides 

• Inactivity 

• Smoking 

• Emotional stress 

Regular follow-up visits with your health care provider / taker are essential. 


385

‣ Drooping of eyelid (ptosis) and weakness 

of ocular muscles 

‣ Decreased reflexes: gag, swallow, pupil 

reactivity to light 

‣ Decreased sensation and muscle 

weakness of the face 

‣ Balance problems and nystagmus 

‣ Altered breathing and heart rate 


386

‣ Weakness in sternocleidomastoid muscle 

with inability to turn head to one side 

‣ Weakness in tongue (inability to protrude 

and/or move from side to side) 

‣ Sudden numbness or weakness of the 

face, arm or leg, especially on one side of 

the body. 


387

Diagnosis 

‣ CT scan for brain hemorrhage 

‣ Conventional angiogram g for view the 

blood vessels 

‣ Carotid Doppler ultrasound for detect 

decreasing blood flow in the carotid 

arteries 

‣ ECG for abnormal heart rhythms 


388

Prevention 

ention 

‣ Strokes are preventable 

‣ Check blood pressure 

‣ Health diet and exercise 

‣ Control diabetes. 

‣ Stop smoking 


389


‣ Speech therapy 

‣ Occupational therapy to regain as much 

function dexterity in the arms and hands as 

possible 


390

‣ Physical therapy to improve 

strength and walking 

‣ Family education to orient 

them in caring for their 

loved one at home and the 

challenges they will face. 


391

Rheumatic heart diseases 


392

Rheumatic heart diseases 

‣ Complication of rheumatic fever 

‣ Usually occurs after attacks of 

rheumatic fever. 


393


‣ Untreated strep throat. 

‣ Damage the heart valves 


394

‣ Breathlessness 

‣ Fatigue 

‣ Palpitations 

‣ Chest pain, and 

‣ Fainting attacks 

Symptoms 


395

Treatment 

Include medication and surgery. 

‣ Medication aim to avoid overexertion. 

‣ Surgery to replace the damaged 

valve(s). 


396

Prevention 

‣ Seek immediate medical attention for 

sore throat 

‣ Do not let it progress to rheumatic fever. 


397

Comprehensive and 

integrated action to prevent 

and control CVDs 

Focus on main risk factors for a range of chronic 

diseases such as CVD, diabetes and cancer 

‣ Comprehensive Tobacco Control Policies 

‣ Healthy diet 

‣ Physical activity, 

‣ Healthy meals 


398


399

National Program for 

Health and Care of Elderly 

l 


400

Conceptualization ation of NPHCE 

UN Convention on the Rights of Persons 

with Disabilities (UNCRPD), 

National Policy on Older Persons 

(NPOP) adopted by the Government of 

India in 1999 & 

Section 20 of “The Maintenance and 

Welfare of Parents and Senior Citizens 

Act, 2007” dealing with provisions for 

medical care of Senior Citizen. 


401

10 th June, 2010 ; 

NPHCE 

Rs.288.00 crore for the remaining period 

of the 11 th five year plan(20% by states ) 

Implemented in 30 districts of 21 states 

during the year 2010-11 and 

70 added during 2011-12. 

Expected to be expanded to the entire 

e 

country during the 12 th Plan. 


402

Objectives 

es 

Provide Preventive, curative and 

rehabilitative services to the elderly 

persons; 

To strengthen referral system; 

To develop specialized man power and 

to promote research in the field of 

diseases related to old age. 


403

Ageing 

Age-related changes in molecules and 

cells (theories of ageing) 

Normal ageing and associated disorders 

of key physiological systems 

Influence of environment and lifestyle. 

l 


404

Ageing 

Ageing is a progressive biological process 

Ageing is not a disease. 


405

Common terms 

Elderly 

Senior Citizen 

Aged 

Old Person 

Older Person 


406

Ageing means….. 

Demographers: A Number 

Economists: A Burden 

Politicians: A Vote 

Medical Doctors: A Case 

Nurses: A Patient 

t 

You: 


407

Global Population 60 + Years : 

1980-2020 

1980 1990 2000 2010 2020 

World 8.6 9.2 9.9 10.8 12.9 

Developed e 15.2 16.8 68 18.4 19.7 22.4 

Developing 6.3 7 7.7 8.7 10.9 

Africa 4.9 4.8 4.8 4.9 5.6 

Latin America 6.5 7 7.7 8.8 11 

Asia (excl. Japan) 6.5 7.4 8.5 9.8 12.8 

China 7.4 9 10.5 12.4 16.6 

India 6.5 7.3 8.4 9.9 12.6 

Source : United Nations , World Demographic Estimate and Projections 


408

Ageing 

Progressive and generalized impairment of functions 

loss of adaptive response to stress and increasing 

risk of age-related diseases. 

UN -‘ageing population’ proportion of people over 60 

reaches 7 per cent 

As per 2001 census people aged 60 and above 

constituted about 7.7% of the total population (up 

from 6.7 % in 1991). 

It is projected to rise to about 172 million by the year 

2026 (about 12 % of the total population) 


409

Some Facts! 

Aging is an end product of demographic 

transition. 

The number of elderly people in 

developing countries is almost 3-4 times 

of that of developed countries. 

The developed d countries ti have already 

experienced the consequences of this 

transition. 


410

Some Facts! 

World population of 6.9 billion in 2011 is 

likely to become 7.5 billion in 2020 

Global aged population is 86.5 million 

(2011) 

Global l aged population constitutes 0.8% 

of world population.(2011) 

Source:HDR-2011,UNDP and UN, Population Division, Department of Economic and Social 

Affairs ( World Population Prospects: The 2010 Revision) 


411

Some Facts! 

73 % of deaths in the elderly are related 

to heart diseases, smoking and cancers. 

20% of doctor’s visits, 30 % of hospital 

days and 50% of bedridden days are 

ascribed to elderly patients. 

‘Ageing adds to BOD due to chronic 

non-communicable diseases. 


412

Projections 

60+ 24 million in 1961 increased to 86.5 

million in 2011. 

Projected to rise to 179 million in 2031 

and 301 million in 2050. 

70 and above projected to increase from 

45 million in 2011 to 146 million in 2050. 

80+ would be fastest to grow – 21 million 

in 2011 to 40 million in 2050. 

Source:HDR-2011,UNDP and UN, Population Division, Department of Economic and Social 

Affairs ( World Population Prospects: The 2010 Revision) 


413

India: Some Facts! 

2 nd largest elderly (60+) population p in the 

world (2010) 

Elderly(60+) :-100.819 million 

Source : United Nations , Population Division, Department of Economic and Social Affairs 

(World Population Prospects: The 2010 Revision) 

80% are in rural areas 

40% are below poverty line 

Over 73 per cent are Illiterate. 

about 90 % of the old people have no official 

social security (i.e., without PF, Gratuity and 

Pension etc). 


414

India: Some Facts! 

Life expectancy 31.7 years in 1941 increased 

to 66.9 years (Census 2011) and 65.4 years(HDR-2011,UNDP) 

in 2011. 

55% of the women of 60 years and above are 

widows. 

Older women most vulnerable. 

Elderly poverty is a major risk of ageing in 

developing countries. 


415

Household population 

p 

+ 60 Age 

9 

8.5 

8.9 

Rural 

Urban 

85 8.5 Total 

8 7.7 

7.5 

7 

Source : NFHS-III 


416

Household population 

p 

+ 60 Age By Sex 

8.6 

8.58 

8.56 

8.54 

8.52 

8.5 

8.48 

8.46 

8.44 

8.6 

8.5 8.5 

Male 

Female 

Total 

Source : NFHS-III 


417

Not just the numbers… 

Family structure is changing to 

nuclear/small unit families. 

Without t the safe, secure and dignified 

ifi d 

status in the family, the elderly are 

finding themselves vulnerable. 

Welfare of the elderly has been a low 

priority with the state… 


418

Ageing: Common Myths 

Most elderly need long-term care 

Anyone over a certain set age (such as 65) is 

old 

Elderly people are incompetent 

All elderly l people live in poverty 

Older people are unhappy and lonely 

Elderly l individuals id do not want to work, and 

prior to retirement, they lose interest in work 

Retired people feel dejected 

d 


419

Ageing process 

Physical changes are a normal part of 

the aging process 

Rate and degree of change varies 

Usually related to a decreased function 

of body systems 

Recognizing normal changes allows the 

individual to adapt and cope 


420

Integumentary System 

Production of new skin cells decreases 

Sebaceous (oil) and sudoriferous 

(sweat) glands become less active 

Circulation to skin decreases 

Hair loses color; hair loss may occur 


421

Musculoskeletal System 

Muscles lose tone, volume, and strength 

Osteoporosis 

Arthritis 


422

Circulatory System 

Heart muscle becomes less efficient at 

pushing blood into the arteries 

Blood vessels narrow and become 

less elastic 

Blood flow may decrease to brain and 

other vital organs 


423

Respiratory System 

Respiratory muscles become weaker 

Rib cage becomes more rigid 

Bronchioles lose elasticity 

Changes in larynx affect voice 


424

Nervous System 

Progressive loss of brain cells 

Decreasing Senses 

Poor adaptation to changes 


425

Digestive e System 

Reduced secretions and enzymes 

Slower smooth Muscle action 

peristalsis decreases 

Teeth are lost 

Liver function is reduced 


426

Urinary System 

Decreased circulation to kidneys 

Decreased number of nephrons 

• Kidneys decrease in size; are less efficient 

Bladder function weakens 


427

Endocrine System 

Increased/ decreased production of 

some hormones 


428

Reproductive e System 

Female: vaginal walls thin and secretions 

decrease; decreased support of uterus; 

breasts sag when fat is redistributed 

Male: production of sperm decreases; 

response to sexual stimuli is slower; 

ejaculation takes longer; testes become 

smaller and less firm; seminal fluid becomes 

thinner and less is produced 

d 


429

Aging causes many physical changes in all 

body systems; rate and degree vary 

All experience some degree of change 

Adapting and coping means fuller enjoyment of 

life within physical limitations 

Tolerance, patience, and empathy 

are essential 


430

Psychosocial Changes 

of Aging 

Loneliness 

Dependency 

Failure to adjust 

Feeling of vegetative ti life 

Irritability 

Dejection 

Depression 


431

Disease and Disability 

Elderly people are more prone to 

disease and disability 

Diseases sometimes cause 

permanent disabilities 

When functioning is 

affected, psychological stress is 

experienced 

Sick people often have fear of 

death, chronic illness, loss of 

function, and pain 


432

Psychosocial changes can be a major 

source of stress 

As changes occur, individuals must learn 

to accommodate the changes and 

function in new situations 

With support, understanding, and 

patience, health care workers can assist 

individuals id asthey learn to adapt 


433

Confusion and Disorientation 

in the Elderly 

Most remain mentally alert until death 

Signs of confusion or disorientation 

It is sometimes a temporary condition 

Disease and/or damage to the brain can 

result in chronic confusion or 

disorientation 


434

Dementia 

Term used to describe a loss of 

mental ability 

Characteristics include decrease in 

intellectual ability, loss of memory, and 

personality change 

Acute dementia 

Chronic dementia 


435

Alzheimer’s Disease 

One form of dementia 

Causes progressive changes in brain 

cells 

Lack of neurotransmitter 

Frequently occurs in 60s, but can occur 

as young as 40 years of age 

Cause is unknown 


436

Alzheimer’s Disease 

(continued) 

Terminal incurable brain disease; usually 

lasting 3-10 years 

Early stage 

Middle stage 

Terminal stage 


437

Caring for the Confused or 

Disoriented Patient 

Provide safe and secure environment 

Follow the same routine 

Follow “reality orientation” guidelines 

Caring for a confused or disoriented individual can 

be frustrating and even frightening 

Perform continual assessments 

Design program to maximize function 

Practice ce patience, consistency, s cy, and sincere e caring 


438

Meeting the Needs 

of the Elderly 

Geriatric care can be challenging 

but rewarding 

Elderly people have the same needs 

as others 

Cultural needs 

Religious needs 

Freedom from abuse 

Respect patient’s rights 


439

Common problems with Ageing 

Nutrition- Digestion, Denture, Taste 

Arthritis-Exercise, movement restriction 

Smoking-Whiling time, addiction 

Alcohol – slowed metabolism 

Accidents-Fall, decreased vision 

Adverse dug reactions: Overdose-forgetfulness 

CVDs, Hypotension, Syncope 

Incontinence 


440


441

Social status of older Indians 

General lowering of social status 

Dependency-Burden. 

Authority weakened 

Elderly abuse (30%) 


442

Gender and Ageing g in India 

Discrimination on account of gender, widowhood 

and age‘, ( and poverty ). 

Widowhood, -lowers the socio-economic level of 

women. 

Most older women are either illiterate or poorly 

educated. 

Low social status, discriminatory practices, food 

taboos, and poor attention to health are 

responsible for the poor health of older women ( 

more prone to chronic disabilities ). 


443

Services for Elderly in India da 

Constitutional and legal provisions. 

Maintenance and welfare of parents and senior 

citizens Bill 2007 

Ministry of Social Justice & Empowerment 

National policy on older persons 

• January, 1999. areas of intervention -- 

financial security, healthcare and nutrition, 

shelter, education, welfare, protection ti of life 

and property etc. for the wellbeing of older 

persons in the country. 

National Council for Older Persons 

• Constituted by the Ministry of Social Justice 

and Empowerment to operationalise the 

National Policy on Older Persons. 


444

Care – 

Services for Elderly l in India 

"Old Age Social and Income Security (OASIS)“ 

The Scheme of assistance to Panchayati Raj Institutions/Voluntary 

Organizations/Self Help Groups for construction of old age 

homes/multi service centers for older persons 

Old age pension for the general public 

• National Old Age Pension (NOAP) Scheme. 

Annapurna (schemes & programs to provide food & security ). 

Pension, family pension, widow’s pension and Gratuity. 

Relief in taxation 

Insurance schemes for elderly 

Travel 

Miscellaneous 

• Telephone, Helpline, Expeditious disposal of Court cases, 

Banking, Magazines for the elderly 


445

Role of NGO’s & Private 

Help Age India 

Sectors 

Age-well foundation in Delhi 

Dignity foundation 

The center for old in Need (COIN), 

Age care India 

The Self Employed Women’s 

Association (SFWA) 

Centre for Health Education, Training 

and Nutrition Awareness (CHETNA) 


446

Primary Health Center 

Training of medical and Para medical staff 

Provide basic medical care for common illnesses and 

follow-up ,coordinate rehabilitative services. 

Identify patients who would need the specialist care. 

Provide preventive services like immunization, health 

education and screening. 

These centers will be equipped with the basic 

investigative facilities also. 

The MMU could visit these centers also for 

organizing medical camps and care.

Secondary Care Hospital 

Comprehensive health care service with 

multidisciplinary approach 

A special Geriatric unit 

The hospital -elderly friendly particularly with the 

architect and behavior and communication skills of 

the staff. 

Separate investigations lab & imaging facilities for 

elderly. 

Mobile medical unit will also located here. 

The Geriatric unit will maintain close liaison with 

Primary care center and community. 


448

How to achieve it 

Ati Active advocacy at various levelsl of planning 

Most of the infrastructure and health care 

services already exist in the country 

Need for reorganization of the facilities and 

approach 

Efforts to be made to revive cultural values and 

reinforce the traditional practice of 

interdependence d among generations 

Reinforcing the existing familism 


449

Thank You 


450

Mental Health : 

Problem, Strategies and 

Program 

Non-Communicable Diseases: 




451

Key Facts 

More than 450 million people p suffer from mental 

disorders. Many more have mental problems. 

Mental health is an integral part of health; indeed, 

there is no health without mental health. 

Mental health is more than the absence of mental 

disorders. d 

Mental health is determined by socio-economic, 

biological and environmental factors. 

Cost-effective intersectoral strategies and 

interventions exist to promote mental health. 


452

Health 

"Health is a state of complete physical, 

mental and social well-being and not 

merely the absence of disease or 

infirmity.“ 

Mental health is an integral and 

essential component of health. 


453

Mental Health 

Mental health is a state of well-being in 

which an individual realizes his or her own 

abilities, can cope with the normal stresses 

of life, can work productively and is able to 

make a contribution to his or her 

community. 

In this positive sense, mental health is the 

foundation for individual well-being and the 

effective functioning of a community. 


454

Mental Health Problems in 

India 

1%----Severe Mental Disorder (Schizophrenia, 

Other psychoses)-10-12 millions 

10% ---Minor mental disorders(Anxiety, 

neurotic disorders)-100 millions 

20-30% attending General clinical settings 

suffers from underlying psychiatric disorders 

Suicide rate- 10 per lac population 

1-2% of all children have underlying M H 

Problem. 

051% 0.5-1% of all children have Mental Retardation. 


455

Major Drug Abuse: India 

Drug 

NHS(Current 

DAMS (% among 

Type prevalence,%) treatment seekers) 

Alcohol 21.4% 43.9 

Cannabis 3.0% 11.6 

Heroin 0.2% 11.1 

Opium 0.4% 8.6 

As per Global Adult tobacco Survey (GATS), India 

(2010), more than one-third (35%) of adults in India use 

tobacco in some form. 

Source : National Survey, 2004 SIHFW: An ISO:9001:2008 certified Institution 

456

Extent of the problem… 

Mental Health Problem In Future 

Projections for 2020 

• Mental illnesses are expected to increase their 

proportion of total global burden of disease 15 

percent 

• The top three causes of disease burden projected 

to be IHD, depression and RTAs 

While psychiatric conditions are responsible for little 

more than 1 % of deaths, account for almost 11 % of 

disease burden worldwide 

Source: White Paper, April 2000: Responding to The Global Burden of Disease(WHO) 


457

Mental Health Resources 

In India 

Psychiatric practice in India 

Psychiatrist 

Allopathic practitioner 

Traditional practitioner 

Faith healer 

Temple healing 

Yoga and meditation ti method 


458

Mental Health Resources In 

India 

Manpower 

Estimated 

Current estimate 

Requirement 

Psychiatrists 11500 4000 

Clinical 17250 500-800 

Psychologists 

Psychiatric Social 23000 400-600 

Workers 

Psychiatric 3000 900-1200 

Nurses 

Source : Health Ministry Annual SIHFW: An Report ISO:9001:2008 2008-2009 certified Institution 

459


India… 

Psychiatric Beds per 10,000 000 population World India 

Total psychiatric beds 1.69 0.25 

Psychiatric beds in mental hospitals 1.16 0.2 

Psychiatric beds in general hospitals 0.33 0.05 

Psychiatric beds in other settings 0.20 0.01 

Professionals per 100,000 population 

Number of psychiatrists 1.20 0.2 

Number of psychiatric nurses 2.0 

0.05 

Number of psychologists 0.60 

0.03 

Number of social workers 0.40 

0.03 

(WHO country profile 2001) 


460


India… 

The Indian Psychiatric Society (2011), 4000 

registered psychiatrists in this country. 

If equitably distributed, this translates to just 

one psychiatrist for every three lakh population 

Currently the total numbers of seats 

recognized and permitted by the MCI are 266 

for MD in Psychiatry and 124 for DPM, 49 

students qualify for DNB Psychiatry . 

(http://mciindia.org/tools/medical_colleges/courses.htm accessed on 

17th August 2010). 


461

Health Budget – 

Allocation to Mental Health in India 

Year Total Health 

Budget Crore 

Mental Health 

Budget (Crore 

% Spend on 

Mental Health 

rupees) rupees) 

2006-2007 8207 50(NMHP) 0.60 

2007-2008 15291(10890 

NRHM) 

2008-2009 16534(12050 

NRHM ) 

70(NMHP) 0.45 

70(NMHP) 0.42 

11 Plan period 

(2007-2012) 

152910 1000(NMHP) 0.66 

Budget for mental health increasing but still it is less then 1% and most of 

other developed country. SIHFW: An ISO:9001:2008 certified Institution 

462

Mental Health Resources in 

India 

25000 beds in 37 mental hospitals 

3000-4000 beds in general & teaching 

hospital 

One psychiatric bed per 30000 

population 

5000-6000 qualified psychiatrists, 1500 

clinical psychologist and 800-1000 

psychiatric social workers 

One psychiatrist per 3lacspopulation 

p 


463

Aims : 

National Mental Health Program 

1982 

• Prevention and treatment of mental and neurological 

disorders and their associated disabilities. 

• to improve general health services. 

• Application of mental health in total national development 

to improve quality of life 


464

Objectives 

National Mental Health 

Program 

1. Ensure availability and accessibility of minimum 

mental health care for all 

2. Encourage application of mental health knowledge 

in general health care and in social development. 

3. Promote community participation in the mental 

health services development and to stimulate 

efforts towards self-help in the community. 


465

District Mental Health Programme 

• Developed by NIMHANS in Bellary 

• Start under the National Mental Health 

Programme 1996–97 

• Currently forms the central mental health 

intervention as part of the NMHP 

The objective of DMHP : 

• Integration of mental health care with general 

health care and overall socio economic 

development through development of community 

mental health services and community 

involvement 


466

Essentials of DMHP 

1. A decentralized training programme 

2. Provision of mental health in all health facilities 

3. Involvement of all categories of health workers 

4. Provision of essential psychiatric drugs 

5. A simple record keeping 

6. monitor PHC personnel in mental health care 

7. Mental health team at district level, 

8. Referral support 

9. Supervision 

10. Administrative support of local government 


467

Service in DMHP 

Team consisting of psychiatrist, clinical psychologist, 

psychiatric i social worker, psychiatric i nurse, statistician, 

ti ti i 

programme manager, programme assistant 

Medical consultation on difficult cases 

Hospitalization & treatment for psychiatric patients 

including ECT treatment 

Training of medical officers and health personnel 

Support to NGOs 

Linkage with state mental hospital and medical college 

for further referral facilities 


468

Restrategised NMHP 2003 

Components 

Expansion of DMHP to 100 districts 

 

Strengthening and Modernization of State run 

Mental Hospitals 

Upgradation of Psychiatry Wings of Govt. 

Medical colleges/General Hospitals 

IEC activities 

Research and Training in Mental Health for 

improving i the service delivery 


469

Revised NMHP 

[11th Five-Year Plan (‘07–’12)] 

Establish Centres of Excellence in Mental Health by upgrading 

g 

and strengthening of identified existing mental hospitals 

Modernization of state run mental hospitals and up gradation of 

psychiatric i wings of medical colleges/general l hospitals 

DMHP with added components of Life Skills training 

Research & Training 

IEC 

NGOs and Public Private Partnership for implementation 

Effective Monitoring ,Implementation ,Evaluation at 

Central/State/District level 

Support for Central and State Mental Health Authorities 


470

Integration of NMHP in NRHM 

National Rural Health Mission 

• A major initiative of the Government to revamp 

and strengthen the health care delivery system 

• Integration initiated during the 11th five Year 

plan 

• Basic objective of improving mental health 

services and effective outreach of initiatives 

under NMHP with integrate mental health into 

general health system 


471

Need for Integration 

of fNMHPi into NRHM 

Optimal use of existing infrastructure at various levels of 

health care delivery system 

Use of NRHM platform for transfer/flow of funds to the 

states/U.T.s for better accountability and flexibility 

Involvement of state/district level health authorities in the 

programme monitoring & implementation 

Integrated IEC activity under NRHM 

Involvement of NRHM infrastructure for training related to 

mental health in District 

Involving AYUSH practitioners in delivering mental health 

services at grass root level. 

Involvement of community based organisation 

Building of credible referral chains 


472

DMHP Evaluation 

Independent evaluation carried out during 2008- 

2009,the(Indian Council of Marketing Research) 

covering 20 of the 123 districts. 

The main objective was to assess the 

functioning of DMHP objectively and critically 

and to suggest future expansion of the scheme 

along with improvement in implementation 

based upon the evaluation 

To strengthen the services at sub center, PHC, 

CHC level so that the services become more 

accessible 

A need for strong IEC for awareness 

creation/stigma reduction was noted 


473

DMHP Evaluation 

Lessons learnt 

Limited development of the DMHP in its 

operational aspects by the Central agency 

Limited state level capacity to implement 

the DMHP 

Lack of emphasis on creating awareness in 

the community 

Lack of mental health indicators 

Lack of monitoring 


474

NMHP Achievement 

Scheme 

Financial Support 

Provided 

District under DMHP 123 

Up gradation of 85 Psychiatry Wing 

Psychiatry wings of 

Medical colleges/GHs 

Modernization of State 

29 institutions 

run Mental hospitals 

Centers of Excellence 9 Institutions 

Support for new 19 

departments of Mental 

Health disciplinesi SIHFW: An ISO:9001:2008 certified Institution 

475

NMHP Achievement 

43 State-run Mental hospitals/mental 

health institutions. 

292 Departments of Psychiatry in Medical 

Colleges. 

Approx. 30,000 psychiatric beds, PG 

Training Infrastructure: 


476

Failures 

It is top down approach 

It is 

not based on the cultural aspects of 

the country 

It is driven by WHO policies 

The community voices have not been 

included 

The programme is a singular approach of 

DMHP 


477

NMHP Implementation Barriers 

Poor funding in the initial period 

 

Non availability of Psychiatrists and other mental health 

professionals like psychiatric social workers & clinical 

psychologists in many states. 

Limited undergraduate training in psychiatry 

Limited number of models and their evaluation 

Uneven distribution of resources across states 

There is lack of co-ordination at state level 

Little scope for community participation, NGO‘s, Civil 

Society were not involved to take up the activities to 

grass root level. 

Lack of regular & dedicated monitoring and facilitating 

mechanism. 

No operational guidelines for implementation 


478

Urban Mental Health 

Meta analysis by Reddy and Chandrasekhar(1998) 

• Higher prevalence of mental disorders in urban area 

i.e., 80.6%, whereas it was 48.9% in rural area 

• Mental disorders primarily composed of depression and 

neurotic disorders 

• Women often disproportionately bear burden of 

changes associated with urbanization 

• Huge mental health service gap(82-96%) 

• Lack of sub specialty health service and human 

resource deficit in non medical health professional 


479

Improvement In Urban Mental 

Health 

Reorientation of DMHP 

Involvement of private sector and NGO 

Recognition there is huge mental health 

service gap in urban area 

Encouraging specific clinical i l and social 

service research 

Carrying out more health services 

research 


480

NGO Work In INDIA 

SCARF (Schizophrenia Research Foundation): 

SCARF, is a Chennai-based organisation i that Specialises in 

patient of schizophrenia and research. 

Chaitanya: Pune-based organisation 

Runs a half-way home for schizophrenics patient. 

Snehi: Snehi is an organisation committed to community 

mental health care for young people for their psychological 

well being through its community mental health programmes. 

 

Paripurnata: Paripurnata is a Kolkata-based organisation 

It provides shelter, treatment and rehabilitation to women with 

mental illness who have been imprisoned or hospitalised. 


481

NGO Work In India 

Ashra: Ashra is an Orissa-based organisation for the rescue, treatment, 

rehabilitation and resettlement of homeless women with mental illness. 

The Richmond Fellowship Society (India): 

The world's largest network of mental health service providers 

It provides care and psychosocial rehabilitation for persons with mental 

health needs in India and neighboring countries. 

SANJIVINI 

Addressed the mental health needs of our community since 1976. 

It provides free and confidential counselling to anyone faced with situation 

that causes emotional and mental distress. 

 

SUMAITRI 

Delhi based voluntary organization 

It running a crisis intervention centre for people p who are depressed, 

distressed or may be feeling suicidal. 


482

Mental Health NGO 

Activities 

Treatment: care and rehabilitation 

Community-based activities and prevention 

Research and training 

Advocacy and empowerment 


483

NGO Strength And Limitation 

STRENGTHS 

Working in partnership 

Innovation in practice 

Transparency in administration 

LIMITATION 

Sustainability 

Accountability 

Scope 


484

Community Awareness 

Role of media 

Activities 

iti 

Agony aunts columns 

Phone help lines 

Phone in programmes on Radio/TV 

Mental Illness Awareness Week (MIAW) 

First week of October 

Mental Health Camps 


485

School Mental Health Program 

Early detection and treatment 

Training of Teacher 

Impact of Life Skill to Children 

Enhance Psychosocial Competency 

Holistic approach 


486

Tobacco 

As per Global Adult tobacco Survey (GATS), 

India (2010), more than one-third (35%) of 

adults in India use tobacco in some form. 

The prevalence of smokeless tobacco use 

(26%) is almost twice of the prevalence of 

smoking (14%). 

The prevalence of tobacco use among men 

(48%) is more than twice than women (20%). 

Smoking causes a 10-year decrease in life 

expectancy in smokers in India 

It is estimated that smoking will contribute to 

almost a million deaths per year from 2010 . 


487

Changing Trends Of Drug 

Use 

Changing trends of drug use 

A review of several of the rapid situation 

assessments of drug abuse commissioned by the 

UNODC 31 suggests the following trends: 

More younger users 

More female users 

High rates of alcohol l and tobacco consumption 

Increasing rates of opiate use, particularly 

pharmaceutical opiates 

Increasing use of solvents, particularly among 

impoverished populations 


488

Stepped Care Approach in 

Substance Use 

A stepped care approach 

Step 1: Recognition of substance use and related 

problems in the primary health care/general 

hospital setting 

Step 2: Management of hazardous/harmful use at 

the primary care level 

Step 3: Management of moderate to severe 

dependence in primary care and referral to 

specialized units for relapse prevention 

Step 4: Management by mental health or 

addiction specialists 

Step 5: In-patient treatment 


489

Looking Ahead- Challenges 

Challenges 

Very uneven distribution of resources 

Low allocation of budget 

Low human resources for mental health 

Poor training in psychiatry at UG level 

Lack of welfare programmes. 

Public ignorance 

Stigma with psychiatry Hope 

Increasing interest from the State 

Increasing allocation of budget 

Centre of excellence 

Increasing facilities for training of mental health manpower 

Upgrading of departments of psychiatry and mental health 

institutions 


490

Future Direction 

Vision i 2020: Road Map for the Future 

The Need for a Balanced Approach 

Mainstreaming Mental Health 

Psychiatric services should be available to all 

sections. 

Psychiatry should not be seen as a peripheral 

discipline but must become a part of mainstream 

medicine 

Mental health services must become more relevant 

for Indian cultural needs 

Develop public-private partnership and support for 

NGO initiatives 

 

Increasing public awareness about mental 

disorders 


491

Conclusion 

India has been in the forefront of 

addressing mental health problems of its 

people. 

p 

Programmes and initiative not spread 

widely. 

Large treatment gap. 

Larger problem of the chronically mental ill. 

The stigma of mental illness await major 

initiative to fight. 

Comprehensive service of promotion, 

prevention and treatment have just been 

started. 


492

For more details log on to 

www. sihfwrajasthan.com 

or 

contact : Director-SIHFW on 

sihfwraj@yahoo.co.in 

h i 


493

Non-Communicable Diseases: NPCDCS ... - SIHFW Rajasthan

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